HospitalInspections.org

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Based on observation and interview during the survey, the Facility did not ensure that the Type II (222) East Wing was separated from the adjacent Type I (332) T-Wing Building with at least 2-hour construction.

Findings:

a. On 02/11/13 at 1:48PM a partially sealed conduit penetration in the 2-hour wall separating the two (2) buildings (above cross-corridor doors near the 2nd Floor Pre-Admission Testing Area). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

b. On 02/11/13 at 2:00PM, a partial conduit penetration in the 2-hour wall separating the two (2) buildings (above cross-corridor doors near the 2nd Floor Clinical/Operation Manager's Office and Room #234). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and interview during the survey, the Facility did not ensure that existing interior finishes in rooms that lacked automatic sprinkler protection were of Class A or Class B materials.

Findings:

On 02/12/13 at 11:32AM, the 1st Floor Chapel in the T-Wing Building was found to have wood paneling. This room lacked sprinkler protection. As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they did not know what the fire rating of the wooden paneling was but that they will submit a waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.2, 10.2.3, NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and interview during the survey, the Facility did not ensure that corridor walls in non-sprinkler protected smoke compartments were continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and that they had a fire resistance rating of not less than ½-hour.

Findings:

a. On 02/11/13 at 10:58AM, a partially sealed cable penetration and a cable penetration that was partially sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam) were found in a 4th Floor corridor wall (vicinity of the entrance to the Critical Care Suite near Room #420) in the T-Wing Building.

b. On 02/11/13 at 11:37AM, a duct penetration of a 3rd fFoor corridor wall (vicinity of the entrance to the Neuro/Surgical Intensive Care Unit near Room #321) in the T-Wing Building that contained a fire damper was found to have been sealed with firestopping materials. This is a concern because intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly. As per concurrent interview with the Facility's Director of Engineering, he was not sure what type of firestopping materials were used to seal this duct but that he will investigate this issue and ensure that only approved materials and methods are used to seal duct penetrations containing fire dampers.

c. On 02/11/13 at 1:13PM, a partially sealed cable penetration was found in a T-Wing Building 2nd Floor corridor wall (vicinity of Rooms #221 and #222).

d. On 02/12/13 at 10:51AM, an unsealed cable penetration and a plumbing penetration that was partially sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam), were found in a T-Wing 1st Floor corridor wall (vicinity of the Radiology Department Reception/Waiting Area).

e. On 02/12/13 at 10:55AM, two (2) unsealed cable penetrations were found in a T-Wing 1st Floor corridor wall (vicinity of the Radiology Department X-Ray Waiting Area).

As per concurrent interview with the Facility's Director of Engineering, he will have all of the above-mentioned penetrations completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and interview during the survey, the Facility did not ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

a. On 02/12/13 at 10:10AM, the inactive leaf of the pair of double doors to a T-Wing Building 1st Floor electrical closet (vicinity of the Main Lobby and Exit Stair "D") was not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

b. On 02/12/13 at 10:10AM, the inactive leaves on two (2) sets of double corridor doors to a T-Wing Building 1st Floor Radiology Department CAT Scan Suite were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

c. On 02/12/13 at 2:49PM, the inactive leaf of the pair of double doors to an ED (Emergency Department)-Wing Building Lower-Level Electrical Room (the "Original" Electrical Room) were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

d. On 02/12/13 at 2:52PM, the inactive leaf of the pair of double doors to a ED-Wing Building Lower-Level Mechanical Room were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

As per concurrent interviews with the Facility's Director of Engineering, he will have all of the above-mentioned manually-operated flush bolts replaced with automatic flush bolt positive latching hardware.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and interview during the survey, the Facility did not ensure that smoke barrier walls were constructed to have at least a ½-hour fire resistance rating.

Findings:

a. On 02/12/13 at 8:25AM, an electrical junction box that had been incorporated into the construction of a Main Floor smoke barrier wall in the ED (Emergency Department)-Wing Building (vicinity of corridor doors at the entrance to the Emergency Department Main Treatment Suite, near the Pediatric Exam Room) was found to only be partially sealed with firestopping. As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

b. On 02/12/13 at 8:33AM, an unsealed cable penetration was found in a Main Floor smoke barrier wall in the ED-Wing Building (vicinity of Emergency Department Main Treatment Suite and a Clean Utility/Nourishment Room). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and staff interview during the survey, the Facility did not ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

a. On 02/11/13 at 2:38PM, the door to an East Wing Building 2nd Floor Outpatient Procedures Unit Storage Room was found to lack a self-closing device.

b. On 02/11/13 at 2:40PM, the door to an East Wing Building 2nd Floor Storage Room (Room #282) was found to lack a self-closing device.

c. On 02/12/13 at 9:07AM, the door to a Emergency Department Wing Building Main Floor Pre-Admission Testing Area Storage Room was found to lack a self-closing device.

d. On 02/12/13 at 10:00AM, the door to a T-Wing Building 1st Floor Human Resources Area File Storage Room was found to lack a self-closing device.

As per concurrent interview with the Facility's Director of Engineering, he will have approved self-closing or automatic closing devices installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based observation and staff interview during the survey, the facility did not ensure that openings into exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

a. On 02/11/13 at 10:31AM, a door from a T-Wing Building 5th Floor Mechanical Room (i.e., MER 504-Elevator Machine Room) was found to open directly into an exit enclosure (Exit Stair "D"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

b. On 02/11/13 at 10:33AM, a door from a T-Wing Building 5th Floor Mechanical Room (i.e., MER 502-HVAC/Electrical Equipment Room) was found to open directly into an exit enclosure (Exit Stair "D"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

c. On 02/13/13 at 10:25AM, a door from a T-Wing Building Basement Mechanical Room was found to open directly into an exit enclosure (Exit Stair "E"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.1, 7.1.3.2.1 (d)
10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based observation and staff interview during the survey, the Facility did not ensure that exit stairs had handrails on both sides.

Findings:

On 02/12/13 at 3:02PM, a portion of the North Exit Stair from the ED-Wing Building Lower-Level was found to lack a handrail on one (1) side of the staircase (vicinity of the upper landing area). As per concurrent interview with the Facility's Director of Engineering, he will install a handrail in this location as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.4.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based observation and staff interview during the survey, the Facility did not ensure that all means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 02/12/13 at 11:12AM, a large rolling storage cart and a rolling garbage receptacle were found to be improperly stored within the T-Wing 1st Floor exit stair enclosure (Exit Stair "B"). As per concurrent interview with the Facility's Director of Support Services, he stated that these items are not allowed to be stored in an exit enclosure. He took immediate corrective action and removed both the storage cart and garbage receptacle from this exit staircase.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 7.1.10.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and staff interview during the survey, the Facility did not ensure that all fire sprinklers were maintained free of foreign material.

Findings:

On 02/12/13 at 1:35PM, a build-up of a foreign material (e.g., paint) was noted on an automatic sprinkler in the East-Wing Building 1st Floor Engineering Department-Plumber's Shop. As per concurrent interview with the Facility's Director of Engineering, he will have the vendor who maintains the sprinkler system replace this sprinkler as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on record review and staff interview during the survey, the Facility did not ensure that all cooking facilities were protected in accordance with applicable requirements. Specific reference is made to the lack of monthly visual inspections for the following items:

- The extinguishing system is in its proper location.

- The manual actuators are unobstructed.

- The tamper indicators and seals are intact.

- The maintenance tag or certificate is in place.

- No obvious physical damage or condition exists that might prevent operation.

- The pressure gauge(s), if provided, is in operable range.

- The nozzle blowoff caps are intact and undamaged.

- The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

Findings:

a. On 02/12/13 at 10:18AM, review of monthly inspection tags in the T-Wing Building 1st Floor Kitchen/Food Preparation Area of the "Bistro" Coffee Shop, and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the Facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

b. On 02/12/13 at 1:50PM, review of monthly inspection tags in the East-Wing Building 1st Floor of the Main Kitchen Area and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the Facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

c. On 02/12/13 at 1:59PM, review of monthly inspection tags in the East-Wing Building 1st Floor of the Cafeteria Food Preparation/Cooking Area and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.2.1, NFPA 17A, Standard for Wet Chemical Extinguishing Systems: 5-2

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observation and staff interview during the survey, the Facility did not ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in cooking areas.

Findings:

On 02/12/13 at 1:53PM, the Facility was found to lack the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable "K" type fire extinguisher in the East-Wing Building 1st Floor of the Main Kitchen Area. The required placard shall state "WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used". As per concurrent interview with the Facility's Director of Engineering, he will have the required placard installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observation and staff interview during the survey, the Facility did not ensure that electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations were mounted at least 60-inches above the finished floor as a precaution against their physical damage.

Findings:

a. On 02/11/13 at 11:51AM, it was noted that the light switch in a T-Wing Building 4th Floor Oxygen Storage Room (vicinity of the 4 North Unit Patient Shower Room) was approximately 46-inches above the floor. Electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations are required to be mounted at least 60-inches above the finished floor.

b. On 02/11/13 at 11:51AM, it was noted that the light switch in a T-Wing Building 2nd Floor Oxygen Storage Room was approximately 53-inches above the floor.

c. On 02/11/13 at 1:53PM, it was noted that the light switch in a East-Wing Building 2nd Floor Oxygen Storage Room (2 Main Unit) was approximately 48-inches above the floor.

As per concurrent interview with the Facility's Director of Engineering, he will have the above-mentioned light switches relocated so that they are at least 60-inches above the floor.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2
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1. Based on observation, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that emergency power system wiring was separated from normal system wiring.

The findings include, but are not limited to, the following:

a. On 02/11/13 at 10:50AM, wiring from emergency power system panels "LPE-2" and "PHE4" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502- HVAC/Electrical Equipment Room were found to be in the same electrical wiring raceway as wiring from normal power system panel "MSP2" without any physical separation. As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital. He said that he will have the normal wiring separated from the emergency wiring as soon as possible but that he may need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

b. On the morning of 02/11/13, wiring from emergency power system panel "EM4 A" in T-Wing Building 4th Floor Electrical Room (vicinity of Room #420 and the ICU Waiting Room on the 4 South Unit) was found to be in the same electrical wiring raceway as wiring from normal power system panel "E4A" without any physical separation.

c. On the morning of 02/11/13, wiring from emergency power system panel "EM4 B" in T-Wing Building 4th Floor 4 North Unit Electrical Room was found to be in the same electrical wiring raceway as wiring from normal power system panels "E4B Section 1" and "E4B Section 2" without any physical separation. As per interview with the Facility's Director of Engineering on 02/11/13 at 11:08AM, he believed that this wiring dated back to when this building was originally constructed back in 1969.

d. On the afternoon of 02/26/13, reviews of NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition, NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition, NFPA 70, National Electrical Code, 1965 Edition, NFPA 70, National Electrical Code, 1968 Edition, and NFPA 70, National Electrical Code, 1971 Edition, revealed that wiring from the emergency power system was required to be separated from normal power wiring at least as far back as 1965.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)


2. Based on observations, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Equipment System wiring or that Emergency System-Critical Branch wiring was separated from Equipment System wiring.

The findings include, but are not limited to, the following:

a. On 02/11/13 at 10:53AM, emergency electrical panel board "LPE-2" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502-HVAC/Electrical Equipment Room was found to serve both Emergency System-Life Safety Branch loads (e.g., Circuits #10 and #12 elevator cab control, communication, and signal systems) and Equipment System loads (e.g., Circuits #19, #21 and #23, "Time Clock for X-Mas Lights", Circuit #4 MICU/CCU exhaust fans). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital. He said that he will have the Emergency System-Life Safety Branch wiring separated from the Equipment System wiring as soon as possible but that the scope of the problem is greater that the Hospital originally anticipated and that he will need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

b. On the afternoon of 02/11/13, wiring from emergency power system panel "ARPA" in East-Wing Building 2nd Floor in Room MER 204 was found to serve both Emergency System-Critical Branch loads (e.g., Operating Room {OR} Scheduling Room, OR doors and timer, Endoscopy Unit) and Equipment System loads (i.e., condensate pump).

c. On 02/12/13 at 2:50PM, emergency electrical panel board "ELS" located in the ED-Wing Building Lower-Level "Original" (i.e., 2002 construction) Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm panel, fire alarm system, exit access corridor lighting) and Equipment System loads (e.g., Trane HVAC equipment control panel). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during the 2001 construction of the ED-Wing Building. He said that he will have the Emergency System-Life Safety Branch wiring separated from the Equipment System wiring as soon as possible but that the scope of the problem is greater that the Hospital originally anticipated and that he will need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

d. On 02/13/13 at 10:35AM, emergency electrical panel board "LB2-E1" in T-Wing Building Basement Electrical Room (the "1974" Electrical Room) was found to serve both Emergency System-Life Safety Branch loads (e.g., fire alarm system) from Equipment System loads (e.g., sump pump, medical air system dryer). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital and that he will apply for a time-limited waiver to correct this issue.

e. On 02/14/13 at 9:13AM, emergency electrical panel board "ELLS" in T-Wing Building 1st Floor Electrical Room (vicinity of the service corridor by the Cardiac Catheterization Laboratory) was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm system, smoke dampers) from Equipment System loads (e.g., duct heaters). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 2007 renovation of the Cardiac Catheterization Laboratory and that he will apply for a time-limited waiver to correct this issue.

f. On 02/14/13 at 9:20AM, emergency electrical panel board "ELEQ" in T-Wing Building 1st Floor Electrical Room (vicinity of the service corridor by the Cardiac Catheterization Laboratory) was found to serve both Emergency System-Life Safety Branch loads (e.g., generator alarm panel) from Equipment System loads (e.g., HVAC units "A/C1" and "AHU-1"). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 2007 renovation of the Cardiac Catheterization Laboratory and that he will apply for a time-limited waiver to correct this issue.

g. On 02/14/13 at 9:37AM, wiring from emergency power system panel "LOR2A" in the T-Wing Building 2nd Floor OR Unit was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting and medical gas alarm panel), Emergency System System-Critical Branch loads (e.g., Operating Room and PACU receptacles, Nurse call system), and Equipment System loads (e.g., vacuum pump, sterilizer, hot water heater). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital and that he will apply for a time-limited waiver to correct this issue.

h. On the afternoon of 02/22/13, reviews of both NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition and NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition revealed that wiring for what are now known as the Emergency System-Life Safety Branch wiring and wiring from the Equipment System were required to be separated from each other as far back as 1967.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)


3. Based on observation, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Emergency System-Critical Branch wiring.

The findings include, but are not limited to, the following:

a. On the morning of 02/11/13, wiring from emergency power system panel "EM4 A" in T-Wing Building 4th Floor Electrical Room (vicinity of Room #420 and the ICU Waiting Room on the 4 South Unit) was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas system alarm panels) and Emergency System System-Critical Branch loads (i.e., ICU ice maker, patient room receptacles, ventilator alarms).

b. On the morning of 02/11/13, wiring from emergency power system panel "EM3B" in T-Wing Building 3rd Floor 3 North Unit Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting) and Emergency System System-Critical Branch loads (i.e., #3 North ice maker, patient room receptacles, pneumatic tube system control panel).

c. On the morning of 02/11/13, wiring from emergency power system panel "EM3A" in T-Wing Building 3rd Floor 3 South Unit Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting) and Emergency System System-Critical Branch loads (i.e., Medication Room refrigerator, patient room and SICU Nurse Station receptacles).

d. On the morning of 02/11/13, wiring from emergency power system panel "DR/EM" in East-Wing Building 2nd Floor Outpatient Procedure Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting, exit signs) and Emergency System System-Critical Branch loads (i.e., refrigerator, receptacles).

e. As per interview with the Facility's Director of Engineering on 02/14/13 at 2:45PM and review of waiver records, the facility had been previously cited by the New York State Department of Health for the lack of a code compliant Type 1 Essential Electrical System on the 2nd Floor of the T-Wing Building and that the Department of Health had approved a time-limited waiver, with an expiration date of December 28, 2013, for this issue but that due to scope of the problems with emergency power system that he will submit an amended time-limited waiver request to both the New York State Department of Health and CMS because the facility will need additional time beyond December, 2013 to correct this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551

10NYCRR, 405.24 (b), 711.2 (a) (1) , 711.2 (a) (20)


4. Based on observation and interview during the survey, the Facility did not ensure that the safety of the building containing the healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible structures less than 10-feet from unprotected windows and door openings.

Findings:

a. On 02/13/13 at 10:45AM, a Type (V) (000) construction type modular building (the "Computer Training" Building) was found to have been installed approximately 8-feet from unprotected windows and a wooden deck and stairway that was attached to this modular building was only 4-feet from the unprotected window openings in the Hospital Building (vicinity of the Administration and Human Resources Areas on the 1st Floor of the T-Wing Building). As per concurrent interview with Facility's Director of Engineering, the New York State Department of Health had previously cited this deficiency and that the Department of Health had issued a waiver for it with the contingencies that a hardwired fire alarm and smoke detection system be installed. The building was found to have a hardwired fire alarm and smoke detection system. He said that he will submit waiver request for this deficiency to the Federal Government as well.

b. On 02/13/13 at 10:50AM, a Type (V) (000) construction type modular building (the "Conference/Engineering Office" Building) was found to have been installed approximately 8-feet from unprotected windows in the Hospital Building (vicinity of the Pharmacy and an exit from the 1st Floor of the East-Wing). As per concurrent interview with Facility's Director of Engineering, this building has a hardwired fire alarm and smoke detection system. He also said that he will submit waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.6.2, 4.6.1.2, NFPA 80, Standard for Fire Doors and Fire Windows, NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures

10NYCRR, 405.24 (b), 711.2 (a) (1)


5. Based on observation and staff interview, the Facility did not ensure that power-operated doors in a means of egress were provided with required signage. Specific reference is made to the lack of readily visible, durable signs on the egress side of each door that reads as follows: IN EMERGENCY, PUSH TO OPEN. The sign is required to have letters not less than 1-inch high on a contrasting background.

Findings:

a. On 02/13/13 at 10:37AM, both sets of powered operated sliding exit doors at the T-Wing Building 1st Floor Main Entrance/Exit to the Hospital Lobby were found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

b. On 02/13/13 at 11:02AM, a powered operated sliding exit door at the ED-Wing Building Main Floor Exit to the outside (i.e., the "Service" Exit) found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

c. On 02/13/13 at 11:05AM, both sets of powered operated sliding exit doors at the Emergency Department-Wing Building Main Floor "Ambulance Entrance" were found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

As per concurrent interviews with the Facility's Director of Engineering, he will have the required signage installed on all of the above-mentioned doors as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.2.1, 7.2.1.9.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


6. Based on observation and staff interview during the survey, the Facility did not ensure that the arrangements of all means of egress in the T-Wing Building were in accordance with NFPA 101-2000: 19.2.5.

Findings:

On morning of 02/11/13, it was noted that a designated means of exit access from T-Wing Building exit access corridors on both the 4th and the 3rd Floors were directed through intervening rooms or spaces (e.g., Critical Care Suites located on both of these floors). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on 02/11/13 at 10:56AM, he had an equivalency issued by the Joint Commission for this deficiency in the past and that he will submit a waiver request for this issue as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.9, 7.4, 7.5

10NYCRR, 405.24 (b), 711.2 (a) (1)


7. Based on observation and staff interview during the survey, the Facility did not ensure that all exit discharges were in compliance with NFPA 101-2000 Section 7.7.

Findings:

On 02/12/13 at 10:13AM, Exit Stair "D" in the T-Wing Building was found to discharge to a 1st Floor corridor that lacked approved, automatic sprinkler protection. It was also noted that this corridor would not meet the requirements for an exit passageway. As per concurrent interview with the Facility's Director of Engineering, the New York State Department of Health had previously cited this deficiency and had issued a waiver for it. He said that he will submit waiver request for this deficiency to the Federal Government as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.8, 7.7, 7.2.6

10NYCRR, 405.24 (b), 711.2 (a) (1)


8. Based on observation and staff interview during the survey, the Facility did not ensure that the locations of smoke barriers were accurately identified. Failure to properly identify locations of smoke barriers could cause staff to become confused and, in the event of a fire or smoke condition, to seek refuge in an area that is not, in fact, a safe area of refuge.

Findings:

On 02/14/13 at 8:35AM, a set of cross-aisle doors in the T-Wing Building 2nd Floor Operating Room Suite (vicinity of the Decontamination Packing Room) were identified by signage as being "smoke barrier" doors. As per concurrent interview with the Facility's Director of Engineering, these doors are mislabeled and that there is no smoke barrier at this location. He said that he will have this signage removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7, 19.7.2.1, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)


9. Based on observation and staff interview during the survey, the Facility did not ensure that the integrity of 2-hour fire resistance rated fire barrier walls were maintained.

Findings:

a. On 02/11/13 at 2:35PM, a joist penetration of a 2-hour fire resistance rated fire barrier wall that separated the 2nd Floors of the Type II (222) construction East Wing Building from the Type II (000) construction In-Fill Wing Building was found to not be sealed on one (1) side of the fire barrier wall. As per concurrent interview with the Facility's Director of Engineering, he will have this penetration sealed with approved firestopping materials immediately.

b. On 02/12/13 at 9:05AM, a duct penetration of a 2-hour fire resistance rated exit passageway fire barrier wall (vicinity of Security Post #8 on the Main Floor of the ED-Wing Building) contained a fire/smoke damper was found to have been sealed with firestopping materials. This is a concern because intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly. As per concurrent interview with the Facility's Director of Engineering, he was not sure what type of firestopping materials were used to seal this duct but that he will investigate this issue and ensure that only approved materials and methods are used to seal duct penetrations containing fire/smoke dampers.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.6, 8.2.3, 4.6.12

10NYCRR, 405.24 (b), 711.2 (a) (1)


10. The following deficiencies apply to the free standing, single story multi-tenant Outpatient Building located at 285 Sills Road, Patchogue, New York. This building houses the Hospital's Women's Imaging Center Diagnostic Radiology Outpatient Clinic and is classified as an Existing Business Occupancy (i.e., NFPA101-2000: Chapter 39.

a. Based on observation and staff interview during the survey, the Facility failed to ensure that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 02/13/13 at 9:25AM, both the surveyor and the Facility's Director of Support Services attempted to open the rear exit door from the Women's Imaging Center Diagnostic Radiology Outpatient Clinic but were unable to open it. It was noted that the door could not be opened because it was blocked by a snow and that in addition to the door being blocked that the means of egress (e.g., exterior walkway) from this exit had not been shoveled clear of snow. The surveyor instructed the Facility's Director of Engineering and Director of Support Services that having an inoperable exit from this building was as an unacceptable risk to the building's occupants and that they were to take immediate action by having the snow cleared first from the doorway and then from the remainder of the means of egress (e.g., exterior walkway). The exit door was verified to be cleared of snow and fully operable by 9:47AM. As per interview with the Facility's Director of Engineering at 9:48AM, the snow should have been cleared by their landlord. He said that he would bring this matter to the attention of the Hospital's Administration.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.2, 7.1.10.1, 39.2.7, 7.7

10NYCRR, 405.24 (b), 711.2 (a) (1)

b. Based on observation and staff interview during the survey, the Facility did not ensure that all manufacturers' instructions for electrical equipment are followed as per the requirements of NFPA 70, National Electrical Code.

Findings:

On the morning of 02/13/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles in the DEXA Scan Bone Density Testing Room and in the Staff Lounge of the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/13/13 at 9:37AM, the required monthly testing is currently not being performed in this Clinic but that the Facility will start conducting these tests as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)

10NYCRR, 405.24 (b), 711.2 (a) (1)

c. Based on observation and staff interview during the survey, the Facility did not ensure that temporary wiring had been removed from the building as per the requirements of NFPA 70, National Electrical Code.

Findings:

On 02/13/13 at 9:30AM, temporary wiring was found above the suspended ceiling in the of the Women's Imaging Center Diagnostic Radiology Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the wiring removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, 4.6.1.2, NFPA 70-1999 National Electrical Code: Article 305-3 (d)

10NYCRR, 405.24 (b), 711.2 (a) (1)

d. Based on observation and staff interview during the survey, the Facility did not ensure that the arrangement of all means of egress in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic was in accordance with NFPA 101-2000 Section 39.2.5.1.

Findings:

On the morning of 02/12/13, an exit access corridor in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic was found to direct exiting through a room (i.e., the Staff Lounge). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on at 9:30AM, he believed that New York State Department of Health may have already issued a waiver for this deficiency in the past but will need to check his records. He also said that he will submit a waiver request for this issue to the Federal Government as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.1.2

10NYCRR, 405.24 (b), 711.2 (a) (1)

e. Based on observation, record review and staff interview during the survey, the facility did not ensure that battery powered exit signs and battery powered emergency lighting units in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were inspected and tested.

Findings:

On the morning of 02/12/13, the Facility was noted to have battery powered exit signs and battery powered emergency lighting units. As per interview with the Facility's Director of Engineering on 02/12/13 at 9:50AM, he believed that the building's landlord was responsible for inspection and testing of battery powered exit signs and battery powered emergency lighting units.

On the morning of 02/15/13, review of the Facility's inspection, maintenance, and testing records revealed that there were no records for the monthly inspection and testing of battery powered exit signs and battery powered emergency lighting units at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic.

As per interview with the Facility's Director of Engineering on 02/20/13 at 8:31AM, the landlord was unable to provide any documentation for the inspection and testing of the above-mentioned devices. He said that he will inform the Hospital's Administration of this issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.8, 7.10, NFPA 99-1999 Standard for Health Care Facilities: 13-3.3.2, 3-6.2.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)

f. Based on record review and staff interview during the survey, the Facility did not ensure that the fire alarm system in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were inspected and tested in accordance with the requirements found in NFPA 72, National Fire Alarm Code.

Findings:

On the afternoon of 02/15/13, the Facility was unable to provide any reviews of the inspection and testing fire alarm system at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic. As per interview with the Facility's Director of Engineering on 02/15/13 at 12:15PM, he was having difficulty obtaining these records from the building's landlords but that the vendor responsible for inspecting, maintaining, and testing the fire alarm system at the above-mentioned Clinic was onsite at that moment to inspect and test the fire alarm system.

As per document review and concurrent interview with the Facility's Director of Engineering on 02/20/13 at 8:29AM, the vendor responsible for inspecting, maintaining, and testing the fire alarm system at the above-mentioned clinic had conducted the annual testing and a one of the semi-annual inspections of the fire alarm system on 06/15/12. There was no evidence that the vendor conducted at least one (1) more semi-annual inspection of the fire alarm system in 2012. In addition, there also was no evidence that the vendor has been conducting any of required sensitivity testing of the fire alarm system. The Director of Engineering said that he will inform the Hospital's Administration of these issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.6.1.7, NFPA 72 -1999 National Fire Alarm Code 7-3, 7-5.2

10NYCRR, 405.24 (b), 711.2 (a) (1)

g. Based on record review and staff interview during the survey, the Facility did not ensure that the fire drills in Outpatient Clinics are being conducted at least once per quarter per employee work shift in accordance with New York State Department of Health requirements.

Findings:

As per record review conducted on the afternoon of 02/15/12, the Facility only conducted one (1) fire drill at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic in 2012 (i.e., the 06/13/12 fire drill). As per interviews with the Facility's Director of Support Services and Director of Engineering on 02/15/13 at 12:10PM, they were not aware that the New York State Department of Health has, since June 2001, required that Outpatient Clinics/Diagnostic and Treatment Centers conduct fire drills in accordance with the Health Care Occupancy Chapter of the Life Safety Code. They said that going forward they will comply with this requirement.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.1.2, 4.6.1.2, 4.7.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


11. The following deficiencies apply to the free standing, single story multi-tenant Outpatient Building located at 33 Medford Avenue, Patchogue, New York. This building houses the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic and is classified as an Existing Business Occupancy (i.e., NFPA101-2000: Chapter 39).

a. Based on observation and staff interview during the survey, the Facility did not ensure that all electrical panel board circuits and circuit modifications were legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

Findings:

On the morning of 02/13/12, the panel directories for the Life Safety Branch Emergency Power Panel, the Critical Branch Emergency Power Panel, and the HVAC/Equipment System Emergency Power Panel in the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic were found to lack circuit directories.

As per interview with the Facility's Director of Engineering on 02/13/13 at 8:07AM, he will have the circuits served by these electrical panels identified and circuit directories installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

10NYCRR, 405.24 (b), 711.2 (a) (1)

b. Based on observation and staff interview during the survey, the Facility did not ensure that the integrity of exit stair enclosures was maintained.

Findings:

On 02/13/13 at 8:25AM, an unsealed plumbing penetration was noted in the exit stair enclosure (vicinity of the 2nd Floor landing of the West Exit Stair) in the building that houses the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the penetration sealed with approved firestopping materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.3.1, 8.2.5

10NYCRR, 405.24 (b), 711.2 (a) (1)

c. Based on observation, record review, and staff interview during the survey, the Facility did not ensure that the onsite emergency power generators were inspected at least once every seven (7) days in accordance with NFPA 110, Standard for Emergency and Standby Power Systems Sections 6-3.6 and 6-4.1. Specifically, Section 6-3.6 requires that storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than seven (7) days and shall be maintained in full compliance with manufacturers' specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Section 6-4.1 requires that Level 1 and Level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

On the morning of 02/13/13, the emergency power needs of the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic was noted to be served by an onsite emergency power generator.

As per record review and interview with the Facility's Director of Engineering on 02/13/13 at 8:35AM, the Facility is conducting all required annual, semi-annual, and monthly inspections, testing, and maintenance on the emergency generator but not the required weekly inspections. He said that the facility will start conducting the required inspections as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.3, NFPA 99-1999 Standard for Health Care Facilities: 13-3.3.2, 3-6.1.1, 3-4.1.1, NFPA 110 -1999 Standard for Emergency and Standby Power Systems: 6-3.6, 6-4.1

10NYCRR, 405.24 (b), 711.2 (a) (1)

d. Based on record review and staff interview during the survey, the Facility did not ensure that the automatic sprinkler system in the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

On the afternoon of 02/15/13, review of the inspection, testing, and maintenance records for the automatic sprinkler system at the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic revealed that required inspection and testing of the sprinkler system had not been performed during the 4th quarter of 2012.

As per interview with the Facility's Director of Engineering on 02/20/13 at 8:33AM, the required quarterly inspection and testing of the building's sprinkler system should have been performed. He said that he will bring

.
1. Based on observation and staff interview during the survey, the Facility did not ensure that all manufacturers' instructions for electrical equipment are followed as per the requirements of NFPA 70, National Electrical Code.

Findings:

a. On the mornings of 02/11/13 and 02/14/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles were noted in several locations within the T-Wing Building (e.g., 3rd Floor Soiled Utility Rooms, 1st Floor Endoscopy Suite Scope Washing Area) were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/15/13 at 10:55AM, the Facility currently only conducts required monthly testing of GFCI receptacles located in the Acute/Chronic Dialysis Unit on the 2nd Floor of the T-Wing Building but that the Facility will start conducting these tests as soon as possible.

b. On the afternoon of 02/12/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles were noted in several locations within the East-Wing Building (e.g., 1st Floor Kitchen Suite) were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/15/13 at 10:55AM, the Facility currently only conducts required monthly testing of GFCI receptacles located in the Acute/Chronic Dialysis Unit on the 2nd Floor of the T-Wing Building but that the Facility will start conducting these tests as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observation and staff interview, the Facility did not ensure that the electrical wiring was installed in a neat and workman like manner or maintained in good repair. Specific reference is made to the following requirement: Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Findings:

a. On 02/11/13 at 10:35AM, unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #21) was found in an emergency power system electrical panel "LPE-2" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502-HVAC/Electrical Equipment Room. As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

b. On 02/12/13 at 10:08AM, unprotected openings due to three (3) missing spacer bars were found in an normal power system electrical panel "EGE" in a T-Wing Building 1st Floor electrical closet (located near Exit Stair "D" and the Main Lobby). As per concurrent interview with the Facility's Director of Engineering, he will ensure that approved materials are installed over these openings into this electrical panel immediately.

c. On 02/12/13 at 10:58AM, an unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #20) was found in an emergency power system electrical panel "XD2E" in T-Wing Building 1st Floor Electrical Room (near Radiology Department Ultrasound Room). As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

d. On 02/13/13 at 10:33AM, an unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #24) was found in an emergency power system electrical panel "LB2-E1" in T-Wing Building Basement Electrical Room (the "1974" Electrical Room). As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12 (a)

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observation and staff interview, the Facility did not ensure that all temporary wiring had been removed upon completion of construction.

Findings:

On the morning of 02/12/13, temporary wiring was found above the suspended ceilings in corridors near the entrance to Behavioral Health Intake Area and near the Clean Utility/ Nourishment Room located near an entrance to the Emergency Department (ED) Main Treatment Area on the Main Floor of the ED-Wing Building.

As per interview with the Facility's Director of Engineering on 02/12/13 at 8:34AM, construction of the ED-Wing Building was completed in 2001 or 2002. He said that he will ensure that the temporary wiring in no longer energized and will have it removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 305-3 (d)

10NYCRR, 405.24 (b), 711.2 (a) (1)

.
Based on observation and interview during the survey, the Facility did not ensure that the Type II (222) East Wing was separated from the adjacent Type I (332) T-Wing Building with at least 2-hour construction.

Findings:

a. On 02/11/13 at 1:48PM a partially sealed conduit penetration in the 2-hour wall separating the two (2) buildings (above cross-corridor doors near the 2nd Floor Pre-Admission Testing Area). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

b. On 02/11/13 at 2:00PM, a partial conduit penetration in the 2-hour wall separating the two (2) buildings (above cross-corridor doors near the 2nd Floor Clinical/Operation Manager's Office and Room #234). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.1.4.1, 8.2.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
Based on observation and interview during the survey, the Facility did not ensure that existing interior finishes in rooms that lacked automatic sprinkler protection were of Class A or Class B materials.

Findings:

On 02/12/13 at 11:32AM, the 1st Floor Chapel in the T-Wing Building was found to have wood paneling. This room lacked sprinkler protection. As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they did not know what the fire rating of the wooden paneling was but that they will submit a waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.3.2, 10.2.3, NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials.

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
Based on observation and interview during the survey, the Facility did not ensure that corridor walls in non-sprinkler protected smoke compartments were continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and that they had a fire resistance rating of not less than ½-hour.

Findings:

a. On 02/11/13 at 10:58AM, a partially sealed cable penetration and a cable penetration that was partially sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam) were found in a 4th Floor corridor wall (vicinity of the entrance to the Critical Care Suite near Room #420) in the T-Wing Building.

b. On 02/11/13 at 11:37AM, a duct penetration of a 3rd fFoor corridor wall (vicinity of the entrance to the Neuro/Surgical Intensive Care Unit near Room #321) in the T-Wing Building that contained a fire damper was found to have been sealed with firestopping materials. This is a concern because intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly. As per concurrent interview with the Facility's Director of Engineering, he was not sure what type of firestopping materials were used to seal this duct but that he will investigate this issue and ensure that only approved materials and methods are used to seal duct penetrations containing fire dampers.

c. On 02/11/13 at 1:13PM, a partially sealed cable penetration was found in a T-Wing Building 2nd Floor corridor wall (vicinity of Rooms #221 and #222).

d. On 02/12/13 at 10:51AM, an unsealed cable penetration and a plumbing penetration that was partially sealed with a non-fire resistance rated material (e.g., polyurethane expansion foam), were found in a T-Wing 1st Floor corridor wall (vicinity of the Radiology Department Reception/Waiting Area).

e. On 02/12/13 at 10:55AM, two (2) unsealed cable penetrations were found in a T-Wing 1st Floor corridor wall (vicinity of the Radiology Department X-Ray Waiting Area).

As per concurrent interview with the Facility's Director of Engineering, he will have all of the above-mentioned penetrations completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
Based on observation and interview during the survey, the Facility did not ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

a. On 02/12/13 at 10:10AM, the inactive leaf of the pair of double doors to a T-Wing Building 1st Floor electrical closet (vicinity of the Main Lobby and Exit Stair "D") was not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

b. On 02/12/13 at 10:10AM, the inactive leaves on two (2) sets of double corridor doors to a T-Wing Building 1st Floor Radiology Department CAT Scan Suite were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

c. On 02/12/13 at 2:49PM, the inactive leaf of the pair of double doors to an ED (Emergency Department)-Wing Building Lower-Level Electrical Room (the "Original" Electrical Room) were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

d. On 02/12/13 at 2:52PM, the inactive leaf of the pair of double doors to a ED-Wing Building Lower-Level Mechanical Room were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

As per concurrent interviews with the Facility's Director of Engineering, he will have all of the above-mentioned manually-operated flush bolts replaced with automatic flush bolt positive latching hardware.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
Based on observation and interview during the survey, the Facility did not ensure that smoke barrier walls were constructed to have at least a ½-hour fire resistance rating.

Findings:

a. On 02/12/13 at 8:25AM, an electrical junction box that had been incorporated into the construction of a Main Floor smoke barrier wall in the ED (Emergency Department)-Wing Building (vicinity of corridor doors at the entrance to the Emergency Department Main Treatment Suite, near the Pediatric Exam Room) was found to only be partially sealed with firestopping. As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

b. On 02/12/13 at 8:33AM, an unsealed cable penetration was found in a Main Floor smoke barrier wall in the ED-Wing Building (vicinity of Emergency Department Main Treatment Suite and a Clean Utility/Nourishment Room). As per concurrent interview with the Facility's Director of Engineering, he will have this penetration completely sealed with approved firestopping materials immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
Based on observation and staff interview during the survey, the Facility did not ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors.

Findings:

a. On 02/11/13 at 2:38PM, the door to an East Wing Building 2nd Floor Outpatient Procedures Unit Storage Room was found to lack a self-closing device.

b. On 02/11/13 at 2:40PM, the door to an East Wing Building 2nd Floor Storage Room (Room #282) was found to lack a self-closing device.

c. On 02/12/13 at 9:07AM, the door to a Emergency Department Wing Building Main Floor Pre-Admission Testing Area Storage Room was found to lack a self-closing device.

d. On 02/12/13 at 10:00AM, the door to a T-Wing Building 1st Floor Human Resources Area File Storage Room was found to lack a self-closing device.

As per concurrent interview with the Facility's Director of Engineering, he will have approved self-closing or automatic closing devices installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

.
1. Based observation and staff interview during the survey, the facility did not ensure that openings into exit enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings:

a. On 02/11/13 at 10:31AM, a door from a T-Wing Building 5th Floor Mechanical Room (i.e., MER 504-Elevator Machine Room) was found to open directly into an exit enclosure (Exit Stair "D"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

b. On 02/11/13 at 10:33AM, a door from a T-Wing Building 5th Floor Mechanical Room (i.e., MER 502-HVAC/Electrical Equipment Room) was found to open directly into an exit enclosure (Exit Stair "D"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

c. On 02/13/13 at 10:25AM, a door from a T-Wing Building Basement Mechanical Room was found to open directly into an exit enclosure (Exit Stair "E"). As per concurrent interview with the Facility's Director of Engineering, he will submit a waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.1, 7.1.3.2.1 (d)
10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based observation and staff interview during the survey, the Facility did not ensure that exit stairs had handrails on both sides.

Findings:

On 02/12/13 at 3:02PM, a portion of the North Exit Stair from the ED-Wing Building Lower-Level was found to lack a handrail on one (1) side of the staircase (vicinity of the upper landing area). As per concurrent interview with the Facility's Director of Engineering, he will install a handrail in this location as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.4.2, 7.2.2.4.2

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based observation and staff interview during the survey, the Facility did not ensure that all means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 02/12/13 at 11:12AM, a large rolling storage cart and a rolling garbage receptacle were found to be improperly stored within the T-Wing 1st Floor exit stair enclosure (Exit Stair "B"). As per concurrent interview with the Facility's Director of Support Services, he stated that these items are not allowed to be stored in an exit enclosure. He took immediate corrective action and removed both the storage cart and garbage receptacle from this exit staircase.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 7.1.10.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observation and staff interview during the survey, the Facility did not ensure that all fire sprinklers were maintained free of foreign material.

Findings:

On 02/12/13 at 1:35PM, a build-up of a foreign material (e.g., paint) was noted on an automatic sprinkler in the East-Wing Building 1st Floor Engineering Department-Plumber's Shop. As per concurrent interview with the Facility's Director of Engineering, he will have the vendor who maintains the sprinkler system replace this sprinkler as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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1. Based on record review and staff interview during the survey, the Facility did not ensure that all cooking facilities were protected in accordance with applicable requirements. Specific reference is made to the lack of monthly visual inspections for the following items:

- The extinguishing system is in its proper location.

- The manual actuators are unobstructed.

- The tamper indicators and seals are intact.

- The maintenance tag or certificate is in place.

- No obvious physical damage or condition exists that might prevent operation.

- The pressure gauge(s), if provided, is in operable range.

- The nozzle blowoff caps are intact and undamaged.

- The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

Findings:

a. On 02/12/13 at 10:18AM, review of monthly inspection tags in the T-Wing Building 1st Floor Kitchen/Food Preparation Area of the "Bistro" Coffee Shop, and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the Facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

b. On 02/12/13 at 1:50PM, review of monthly inspection tags in the East-Wing Building 1st Floor of the Main Kitchen Area and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the Facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

c. On 02/12/13 at 1:59PM, review of monthly inspection tags in the East-Wing Building 1st Floor of the Cafeteria Food Preparation/Cooking Area and concurrent interviews with the Facility's Director of Engineering and the Director of Support Services revealed that the facility has not conducted the required monthly visual inspections of the wet chemical extinguishing system provided in this location but that they would start doing so immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.2.1, NFPA 17A, Standard for Wet Chemical Extinguishing Systems: 5-2

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observation and staff interview during the survey, the Facility did not ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in cooking areas.

Findings:

On 02/12/13 at 1:53PM, the Facility was found to lack the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable "K" type fire extinguisher in the East-Wing Building 1st Floor of the Main Kitchen Area. The required placard shall state "WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used". As per concurrent interview with the Facility's Director of Engineering, he will have the required placard installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observation and staff interview during the survey, the Facility did not ensure that electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations were mounted at least 60-inches above the finished floor as a precaution against their physical damage.

Findings:

a. On 02/11/13 at 11:51AM, it was noted that the light switch in a T-Wing Building 4th Floor Oxygen Storage Room (vicinity of the 4 North Unit Patient Shower Room) was approximately 46-inches above the floor. Electrical fixtures in oxygen and oxidizing gas (i.e., nitrous oxide) storage locations are required to be mounted at least 60-inches above the finished floor.

b. On 02/11/13 at 11:51AM, it was noted that the light switch in a T-Wing Building 2nd Floor Oxygen Storage Room was approximately 53-inches above the floor.

c. On 02/11/13 at 1:53PM, it was noted that the light switch in a East-Wing Building 2nd Floor Oxygen Storage Room (2 Main Unit) was approximately 48-inches above the floor.

As per concurrent interview with the Facility's Director of Engineering, he will have the above-mentioned light switches relocated so that they are at least 60-inches above the floor.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2
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1. Based on observation, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that emergency power system wiring was separated from normal system wiring.

The findings include, but are not limited to, the following:

a. On 02/11/13 at 10:50AM, wiring from emergency power system panels "LPE-2" and "PHE4" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502- HVAC/Electrical Equipment Room were found to be in the same electrical wiring raceway as wiring from normal power system panel "MSP2" without any physical separation. As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital. He said that he will have the normal wiring separated from the emergency wiring as soon as possible but that he may need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

b. On the morning of 02/11/13, wiring from emergency power system panel "EM4 A" in T-Wing Building 4th Floor Electrical Room (vicinity of Room #420 and the ICU Waiting Room on the 4 South Unit) was found to be in the same electrical wiring raceway as wiring from normal power system panel "E4A" without any physical separation.

c. On the morning of 02/11/13, wiring from emergency power system panel "EM4 B" in T-Wing Building 4th Floor 4 North Unit Electrical Room was found to be in the same electrical wiring raceway as wiring from normal power system panels "E4B Section 1" and "E4B Section 2" without any physical separation. As per interview with the Facility's Director of Engineering on 02/11/13 at 11:08AM, he believed that this wiring dated back to when this building was originally constructed back in 1969.

d. On the afternoon of 02/26/13, reviews of NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition, NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition, NFPA 70, National Electrical Code, 1965 Edition, NFPA 70, National Electrical Code, 1968 Edition, and NFPA 70, National Electrical Code, 1971 Edition, revealed that wiring from the emergency power system was required to be separated from normal power wiring at least as far back as 1965.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)


2. Based on observations, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Equipment System wiring or that Emergency System-Critical Branch wiring was separated from Equipment System wiring.

The findings include, but are not limited to, the following:

a. On 02/11/13 at 10:53AM, emergency electrical panel board "LPE-2" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502-HVAC/Electrical Equipment Room was found to serve both Emergency System-Life Safety Branch loads (e.g., Circuits #10 and #12 elevator cab control, communication, and signal systems) and Equipment System loads (e.g., Circuits #19, #21 and #23, "Time Clock for X-Mas Lights", Circuit #4 MICU/CCU exhaust fans). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital. He said that he will have the Emergency System-Life Safety Branch wiring separated from the Equipment System wiring as soon as possible but that the scope of the problem is greater that the Hospital originally anticipated and that he will need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

b. On the afternoon of 02/11/13, wiring from emergency power system panel "ARPA" in East-Wing Building 2nd Floor in Room MER 204 was found to serve both Emergency System-Critical Branch loads (e.g., Operating Room {OR} Scheduling Room, OR doors and timer, Endoscopy Unit) and Equipment System loads (i.e., condensate pump).

c. On 02/12/13 at 2:50PM, emergency electrical panel board "ELS" located in the ED-Wing Building Lower-Level "Original" (i.e., 2002 construction) Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm panel, fire alarm system, exit access corridor lighting) and Equipment System loads (e.g., Trane HVAC equipment control panel). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during the 2001 construction of the ED-Wing Building. He said that he will have the Emergency System-Life Safety Branch wiring separated from the Equipment System wiring as soon as possible but that the scope of the problem is greater that the Hospital originally anticipated and that he will need to apply for a time-limited waiver because it may take a prolonged period for the facility to correct this issue.

d. On 02/13/13 at 10:35AM, emergency electrical panel board "LB2-E1" in T-Wing Building Basement Electrical Room (the "1974" Electrical Room) was found to serve both Emergency System-Life Safety Branch loads (e.g., fire alarm system) from Equipment System loads (e.g., sump pump, medical air system dryer). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital and that he will apply for a time-limited waiver to correct this issue.

e. On 02/14/13 at 9:13AM, emergency electrical panel board "ELLS" in T-Wing Building 1st Floor Electrical Room (vicinity of the service corridor by the Cardiac Catheterization Laboratory) was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas alarm system, smoke dampers) from Equipment System loads (e.g., duct heaters). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 2007 renovation of the Cardiac Catheterization Laboratory and that he will apply for a time-limited waiver to correct this issue.

f. On 02/14/13 at 9:20AM, emergency electrical panel board "ELEQ" in T-Wing Building 1st Floor Electrical Room (vicinity of the service corridor by the Cardiac Catheterization Laboratory) was found to serve both Emergency System-Life Safety Branch loads (e.g., generator alarm panel) from Equipment System loads (e.g., HVAC units "A/C1" and "AHU-1"). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 2007 renovation of the Cardiac Catheterization Laboratory and that he will apply for a time-limited waiver to correct this issue.

g. On 02/14/13 at 9:37AM, wiring from emergency power system panel "LOR2A" in the T-Wing Building 2nd Floor OR Unit was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting and medical gas alarm panel), Emergency System System-Critical Branch loads (e.g., Operating Room and PACU receptacles, Nurse call system), and Equipment System loads (e.g., vacuum pump, sterilizer, hot water heater). As per concurrent interview with the Facility's Director of Engineering, he believed that this wiring was installed during a 1974 renovation and expansion project at this Hospital and that he will apply for a time-limited waiver to correct this issue.

h. On the afternoon of 02/22/13, reviews of both NFPA 76, Essential Electrical Systems for Hospitals, 1967 Edition and NFPA 76A, Essential Electrical Systems for Health Care Facilities, 1973 Edition revealed that wiring for what are now known as the Emergency System-Life Safety Branch wiring and wiring from the Equipment System were required to be separated from each other as far back as 1967.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551

10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)


3. Based on observation, record (i.e., panel board schedule) review, and staff interview during the survey, the Facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Emergency System-Critical Branch wiring.

The findings include, but are not limited to, the following:

a. On the morning of 02/11/13, wiring from emergency power system panel "EM4 A" in T-Wing Building 4th Floor Electrical Room (vicinity of Room #420 and the ICU Waiting Room on the 4 South Unit) was found to serve both Emergency System-Life Safety Branch loads (e.g., medical gas system alarm panels) and Emergency System System-Critical Branch loads (i.e., ICU ice maker, patient room receptacles, ventilator alarms).

b. On the morning of 02/11/13, wiring from emergency power system panel "EM3B" in T-Wing Building 3rd Floor 3 North Unit Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting) and Emergency System System-Critical Branch loads (i.e., #3 North ice maker, patient room receptacles, pneumatic tube system control panel).

c. On the morning of 02/11/13, wiring from emergency power system panel "EM3A" in T-Wing Building 3rd Floor 3 South Unit Electrical Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting) and Emergency System System-Critical Branch loads (i.e., Medication Room refrigerator, patient room and SICU Nurse Station receptacles).

d. On the morning of 02/11/13, wiring from emergency power system panel "DR/EM" in East-Wing Building 2nd Floor Outpatient Procedure Room was found to serve both Emergency System-Life Safety Branch loads (e.g., exit access corridor lighting, exit signs) and Emergency System System-Critical Branch loads (i.e., refrigerator, receptacles).

e. As per interview with the Facility's Director of Engineering on 02/14/13 at 2:45PM and review of waiver records, the facility had been previously cited by the New York State Department of Health for the lack of a code compliant Type 1 Essential Electrical System on the 2nd Floor of the T-Wing Building and that the Department of Health had approved a time-limited waiver, with an expiration date of December 28, 2013, for this issue but that due to scope of the problems with emergency power system that he will submit an amended time-limited waiver request to both the New York State Department of Health and CMS because the facility will need additional time beyond December, 2013 to correct this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551

10NYCRR, 405.24 (b), 711.2 (a) (1) , 711.2 (a) (20)


4. Based on observation and interview during the survey, the Facility did not ensure that the safety of the building containing the healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible structures less than 10-feet from unprotected windows and door openings.

Findings:

a. On 02/13/13 at 10:45AM, a Type (V) (000) construction type modular building (the "Computer Training" Building) was found to have been installed approximately 8-feet from unprotected windows and a wooden deck and stairway that was attached to this modular building was only 4-feet from the unprotected window openings in the Hospital Building (vicinity of the Administration and Human Resources Areas on the 1st Floor of the T-Wing Building). As per concurrent interview with Facility's Director of Engineering, the New York State Department of Health had previously cited this deficiency and that the Department of Health had issued a waiver for it with the contingencies that a hardwired fire alarm and smoke detection system be installed. The building was found to have a hardwired fire alarm and smoke detection system. He said that he will submit waiver request for this deficiency to the Federal Government as well.

b. On 02/13/13 at 10:50AM, a Type (V) (000) construction type modular building (the "Conference/Engineering Office" Building) was found to have been installed approximately 8-feet from unprotected windows in the Hospital Building (vicinity of the Pharmacy and an exit from the 1st Floor of the East-Wing). As per concurrent interview with Facility's Director of Engineering, this building has a hardwired fire alarm and smoke detection system. He also said that he will submit waiver request for this deficiency.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.1.6.2, 4.6.1.2, NFPA 80, Standard for Fire Doors and Fire Windows, NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures

10NYCRR, 405.24 (b), 711.2 (a) (1)


5. Based on observation and staff interview, the Facility did not ensure that power-operated doors in a means of egress were provided with required signage. Specific reference is made to the lack of readily visible, durable signs on the egress side of each door that reads as follows: IN EMERGENCY, PUSH TO OPEN. The sign is required to have letters not less than 1-inch high on a contrasting background.

Findings:

a. On 02/13/13 at 10:37AM, both sets of powered operated sliding exit doors at the T-Wing Building 1st Floor Main Entrance/Exit to the Hospital Lobby were found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

b. On 02/13/13 at 11:02AM, a powered operated sliding exit door at the ED-Wing Building Main Floor Exit to the outside (i.e., the "Service" Exit) found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

c. On 02/13/13 at 11:05AM, both sets of powered operated sliding exit doors at the Emergency Department-Wing Building Main Floor "Ambulance Entrance" were found to lack required "IN EMERGENCY, PUSH TO OPEN" signage.

As per concurrent interviews with the Facility's Director of Engineering, he will have the required signage installed on all of the above-mentioned doors as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.2.1, 7.2.1.9.1

10NYCRR, 405.24 (b), 711.2 (a) (1)


6. Based on observation and staff interview during the survey, the Facility did not ensure that the arrangements of all means of egress in the T-Wing Building were in accordance with NFPA 101-2000: 19.2.5.

Findings:

On morning of 02/11/13, it was noted that a designated means of exit access from T-Wing Building exit access corridors on both the 4th and the 3rd Floors were directed through intervening rooms or spaces (e.g., Critical Care Suites located on both of these floors). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on 02/11/13 at 10:56AM, he had an equivalency issued by the Joint Commission for this deficiency in the past and that he will submit a waiver request for this issue as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.9, 7.4, 7.5

10NYCRR, 405.24 (b), 711.2 (a) (1)


7. Based on observation and staff interview during the survey, the Facility did not ensure that all exit discharges were in compliance with NFPA 101-2000 Section 7.7.

Findings:

On 02/12/13 at 10:13AM, Exit Stair "D" in the T-Wing Building was found to discharge to a 1st Floor corridor that lacked approved, automatic sprinkler protection. It was also noted that this corridor would not meet the requirements for an exit passageway. As per concurrent interview with the Facility's Director of Engineering, the New York State Department of Health had previously cited this deficiency and had issued a waiver for it. He said that he will submit waiver request for this deficiency to the Federal Government as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.8, 7.7, 7.2.6

10NYCRR, 405.24 (b), 711.2 (a) (1)


8. Based on observation and staff interview during the survey, the Facility did not ensure that the locations of smoke barriers were accurately identified. Failure to properly identify locations of smoke barriers could cause staff to become confused and, in the event of a fire or smoke condition, to seek refuge in an area that is not, in fact, a safe area of refuge.

Findings:

On 02/14/13 at 8:35AM, a set of cross-aisle doors in the T-Wing Building 2nd Floor Operating Room Suite (vicinity of the Decontamination Packing Room) were identified by signage as being "smoke barrier" doors. As per concurrent interview with the Facility's Director of Engineering, these doors are mislabeled and that there is no smoke barrier at this location. He said that he will have this signage removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7, 19.7.2.1, 8.3

10NYCRR, 405.24 (b), 711.2 (a) (1)


9. Based on observation and staff interview during the survey, the Facility did not ensure that the integrity of 2-hour fire resistance rated fire barrier walls were maintained.

Findings:

a. On 02/11/13 at 2:35PM, a joist penetration of a 2-hour fire resistance rated fire barrier wall that separated the 2nd Floors of the Type II (222) construction East Wing Building from the Type II (000) construction In-Fill Wing Building was found to not be sealed on one (1) side of the fire barrier wall. As per concurrent interview with the Facility's Director of Engineering, he will have this penetration sealed with approved firestopping materials immediately.

b. On 02/12/13 at 9:05AM, a duct penetration of a 2-hour fire resistance rated exit passageway fire barrier wall (vicinity of Security Post #8 on the Main Floor of the ED-Wing Building) contained a fire/smoke damper was found to have been sealed with firestopping materials. This is a concern because intumescing firestopping materials expand when exposed to heat and would impinge on the duct, possibly crushing the duct, and could prevent the fire/smoke damper from operating properly. As per concurrent interview with the Facility's Director of Engineering, he was not sure what type of firestopping materials were used to seal this duct but that he will investigate this issue and ensure that only approved materials and methods are used to seal duct penetrations containing fire/smoke dampers.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.6, 8.2.3, 4.6.12

10NYCRR, 405.24 (b), 711.2 (a) (1)


10. The following deficiencies apply to the free standing, single story multi-tenant Outpatient Building located at 285 Sills Road, Patchogue, New York. This building houses the Hospital's Women's Imaging Center Diagnostic Radiology Outpatient Clinic and is classified as an Existing Business Occupancy (i.e., NFPA101-2000: Chapter 39.

a. Based on observation and staff interview during the survey, the Facility failed to ensure that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 02/13/13 at 9:25AM, both the surveyor and the Facility's Director of Support Services attempted to open the rear exit door from the Women's Imaging Center Diagnostic Radiology Outpatient Clinic but were unable to open it. It was noted that the door could not be opened because it was blocked by a snow and that in addition to the door being blocked that the means of egress (e.g., exterior walkway) from this exit had not been shoveled clear of snow. The surveyor instructed the Facility's Director of Engineering and Director of Support Services that having an inoperable exit from this building was as an unacceptable risk to the building's occupants and that they were to take immediate action by having the snow cleared first from the doorway and then from the remainder of the means of egress (e.g., exterior walkway). The exit door was verified to be cleared of snow and fully operable by 9:47AM. As per interview with the Facility's Director of Engineering at 9:48AM, the snow should have been cleared by their landlord. He said that he would bring this matter to the attention of the Hospital's Administration.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.2, 7.1.10.1, 39.2.7, 7.7

10NYCRR, 405.24 (b), 711.2 (a) (1)

b. Based on observation and staff interview during the survey, the Facility did not ensure that all manufacturers' instructions for electrical equipment are followed as per the requirements of NFPA 70, National Electrical Code.

Findings:

On the morning of 02/13/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles in the DEXA Scan Bone Density Testing Room and in the Staff Lounge of the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/13/13 at 9:37AM, the required monthly testing is currently not being performed in this Clinic but that the Facility will start conducting these tests as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)

10NYCRR, 405.24 (b), 711.2 (a) (1)

c. Based on observation and staff interview during the survey, the Facility did not ensure that temporary wiring had been removed from the building as per the requirements of NFPA 70, National Electrical Code.

Findings:

On 02/13/13 at 9:30AM, temporary wiring was found above the suspended ceiling in the of the Women's Imaging Center Diagnostic Radiology Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the wiring removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, 4.6.1.2, NFPA 70-1999 National Electrical Code: Article 305-3 (d)

10NYCRR, 405.24 (b), 711.2 (a) (1)

d. Based on observation and staff interview during the survey, the Facility did not ensure that the arrangement of all means of egress in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic was in accordance with NFPA 101-2000 Section 39.2.5.1.

Findings:

On the morning of 02/12/13, an exit access corridor in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic was found to direct exiting through a room (i.e., the Staff Lounge). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per interview with the Facility's Director of Engineering on at 9:30AM, he believed that New York State Department of Health may have already issued a waiver for this deficiency in the past but will need to check his records. He also said that he will submit a waiver request for this issue to the Federal Government as well.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.1.2

10NYCRR, 405.24 (b), 711.2 (a) (1)

e. Based on observation, record review and staff interview during the survey, the facility did not ensure that battery powered exit signs and battery powered emergency lighting units in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were inspected and tested.

Findings:

On the morning of 02/12/13, the Facility was noted to have battery powered exit signs and battery powered emergency lighting units. As per interview with the Facility's Director of Engineering on 02/12/13 at 9:50AM, he believed that the building's landlord was responsible for inspection and testing of battery powered exit signs and battery powered emergency lighting units.

On the morning of 02/15/13, review of the Facility's inspection, maintenance, and testing records revealed that there were no records for the monthly inspection and testing of battery powered exit signs and battery powered emergency lighting units at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic.

As per interview with the Facility's Director of Engineering on 02/20/13 at 8:31AM, the landlord was unable to provide any documentation for the inspection and testing of the above-mentioned devices. He said that he will inform the Hospital's Administration of this issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.8, 7.10, NFPA 99-1999 Standard for Health Care Facilities: 13-3.3.2, 3-6.2.2.1

10NYCRR, 405.24 (b), 711.2 (a) (1)

f. Based on record review and staff interview during the survey, the Facility did not ensure that the fire alarm system in the Women's Imaging Center Diagnostic Radiology Outpatient Clinic were inspected and tested in accordance with the requirements found in NFPA 72, National Fire Alarm Code.

Findings:

On the afternoon of 02/15/13, the Facility was unable to provide any reviews of the inspection and testing fire alarm system at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic. As per interview with the Facility's Director of Engineering on 02/15/13 at 12:15PM, he was having difficulty obtaining these records from the building's landlords but that the vendor responsible for inspecting, maintaining, and testing the fire alarm system at the above-mentioned Clinic was onsite at that moment to inspect and test the fire alarm system.

As per document review and concurrent interview with the Facility's Director of Engineering on 02/20/13 at 8:29AM, the vendor responsible for inspecting, maintaining, and testing the fire alarm system at the above-mentioned clinic had conducted the annual testing and a one of the semi-annual inspections of the fire alarm system on 06/15/12. There was no evidence that the vendor conducted at least one (1) more semi-annual inspection of the fire alarm system in 2012. In addition, there also was no evidence that the vendor has been conducting any of required sensitivity testing of the fire alarm system. The Director of Engineering said that he will inform the Hospital's Administration of these issues.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.6.1.7, NFPA 72 -1999 National Fire Alarm Code 7-3, 7-5.2

10NYCRR, 405.24 (b), 711.2 (a) (1)

g. Based on record review and staff interview during the survey, the Facility did not ensure that the fire drills in Outpatient Clinics are being conducted at least once per quarter per employee work shift in accordance with New York State Department of Health requirements.

Findings:

As per record review conducted on the afternoon of 02/15/12, the Facility only conducted one (1) fire drill at the Women's Imaging Center Diagnostic Radiology Outpatient Clinic in 2012 (i.e., the 06/13/12 fire drill). As per interviews with the Facility's Director of Support Services and Director of Engineering on 02/15/13 at 12:10PM, they were not aware that the New York State Department of Health has, since June 2001, required that Outpatient Clinics/Diagnostic and Treatment Centers conduct fire drills in accordance with the Health Care Occupancy Chapter of the Life Safety Code. They said that going forward they will comply with this requirement.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.1.2, 4.6.1.2, 4.7.2

10NYCRR, 405.24 (b), 711.2 (a) (1)


11. The following deficiencies apply to the free standing, single story multi-tenant Outpatient Building located at 33 Medford Avenue, Patchogue, New York. This building houses the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic and is classified as an Existing Business Occupancy (i.e., NFPA101-2000: Chapter 39).

a. Based on observation and staff interview during the survey, the Facility did not ensure that all electrical panel board circuits and circuit modifications were legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

Findings:

On the morning of 02/13/12, the panel directories for the Life Safety Branch Emergency Power Panel, the Critical Branch Emergency Power Panel, and the HVAC/Equipment System Emergency Power Panel in the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic were found to lack circuit directories.

As per interview with the Facility's Director of Engineering on 02/13/13 at 8:07AM, he will have the circuits served by these electrical panels identified and circuit directories installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13

10NYCRR, 405.24 (b), 711.2 (a) (1)

b. Based on observation and staff interview during the survey, the Facility did not ensure that the integrity of exit stair enclosures was maintained.

Findings:

On 02/13/13 at 8:25AM, an unsealed plumbing penetration was noted in the exit stair enclosure (vicinity of the 2nd Floor landing of the West Exit Stair) in the building that houses the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the penetration sealed with approved firestopping materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.3.1, 8.2.5

10NYCRR, 405.24 (b), 711.2 (a) (1)

c. Based on observation, record review, and staff interview during the survey, the Facility did not ensure that the onsite emergency power generators were inspected at least once every seven (7) days in accordance with NFPA 110, Standard for Emergency and Standby Power Systems Sections 6-3.6 and 6-4.1. Specifically, Section 6-3.6 requires that storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than seven (7) days and shall be maintained in full compliance with manufacturers' specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Section 6-4.1 requires that Level 1 and Level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

On the morning of 02/13/13, the emergency power needs of the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic was noted to be served by an onsite emergency power generator.

As per record review and interview with the Facility's Director of Engineering on 02/13/13 at 8:35AM, the Facility is conducting all required annual, semi-annual, and monthly inspections, testing, and maintenance on the emergency generator but not the required weekly inspections. He said that the facility will start conducting the required inspections as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.3, NFPA 99-1999 Standard for Health Care Facilities: 13-3.3.2, 3-6.1.1, 3-4.1.1, NFPA 110 -1999 Standard for Emergency and Standby Power Systems: 6-3.6, 6-4.1

10NYCRR, 405.24 (b), 711.2 (a) (1)

d. Based on record review and staff interview during the survey, the Facility did not ensure that the automatic sprinkler system in the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic was inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

On the afternoon of 02/15/13, review of the inspection, testing, and maintenance records for the automatic sprinkler system at the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic revealed that required inspection and testing of the sprinkler system had not been performed during the 4th quarter of 2012.

As per interview with the Facility's Director of Engineering on 02/20/13 at 8:33AM, the required quarterly inspection and testing of the building's sprinkler system should have been performed. He said that he will bring

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1. Based on observation and staff interview during the survey, the Facility did not ensure that all manufacturers' instructions for electrical equipment are followed as per the requirements of NFPA 70, National Electrical Code.

Findings:

a. On the mornings of 02/11/13 and 02/14/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles were noted in several locations within the T-Wing Building (e.g., 3rd Floor Soiled Utility Rooms, 1st Floor Endoscopy Suite Scope Washing Area) were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/15/13 at 10:55AM, the Facility currently only conducts required monthly testing of GFCI receptacles located in the Acute/Chronic Dialysis Unit on the 2nd Floor of the T-Wing Building but that the Facility will start conducting these tests as soon as possible.

b. On the afternoon of 02/12/13, Ground Fault Circuit Interrupter (GFCI) duplex receptacles were noted in several locations within the East-Wing Building (e.g., 1st Floor Kitchen Suite) were found to be labeled by the manufacturer "TEST MONTHLY". As per interview with the Facility's Director of Engineering on 02/15/13 at 10:55AM, the Facility currently only conducts required monthly testing of GFCI receptacles located in the Acute/Chronic Dialysis Unit on the 2nd Floor of the T-Wing Building but that the Facility will start conducting these tests as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3 (b)

10NYCRR, 405.24 (b), 711.2 (a) (1)


2. Based on observation and staff interview, the Facility did not ensure that the electrical wiring was installed in a neat and workman like manner or maintained in good repair. Specific reference is made to the following requirement: Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Findings:

a. On 02/11/13 at 10:35AM, unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #21) was found in an emergency power system electrical panel "LPE-2" in T-Wing Building 5th Floor Mechanical Penthouse Room MER502-HVAC/Electrical Equipment Room. As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

b. On 02/12/13 at 10:08AM, unprotected openings due to three (3) missing spacer bars were found in an normal power system electrical panel "EGE" in a T-Wing Building 1st Floor electrical closet (located near Exit Stair "D" and the Main Lobby). As per concurrent interview with the Facility's Director of Engineering, he will ensure that approved materials are installed over these openings into this electrical panel immediately.

c. On 02/12/13 at 10:58AM, an unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #20) was found in an emergency power system electrical panel "XD2E" in T-Wing Building 1st Floor Electrical Room (near Radiology Department Ultrasound Room). As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

d. On 02/13/13 at 10:33AM, an unprotected opening due to one (1) missing spacer bar (vicinity of Circuit #24) was found in an emergency power system electrical panel "LB2-E1" in T-Wing Building Basement Electrical Room (the "1974" Electrical Room). As per concurrent interview with the Facility's Director of Engineering, he will ensure that an approved spacer bar is installed over this unprotected opening into the electrical panel immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12 (a)

10NYCRR, 405.24 (b), 711.2 (a) (1)


3. Based on observation and staff interview, the Facility did not ensure that all temporary wiring had been removed upon completion of construction.

Findings:

On the morning of 02/12/13, temporary wiring was found above the suspended ceilings in corridors near the entrance to Behavioral Health Intake Area and near the Clean Utility/ Nourishment Room located near an entrance to the Emergency Department (ED) Main Treatment Area on the Main Floor of the ED-Wing Building.

As per interview with the Facility's Director of Engineering on 02/12/13 at 8:34AM, construction of the ED-Wing Building was completed in 2001 or 2002. He said that he will ensure that the temporary wiring in no longer energized and will have it removed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 305-3 (d)

10NYCRR, 405.24 (b), 711.2 (a) (1)