HospitalInspections.org

Based on observations and interviews, the facility did not ensure that a 2-hour fire barrier wall was provided to separate the 3-story, not fully sprinklered, Type 11 (000) Original Building (i.e., Center, North and Northwest Wings) from the Main Building (i.e., Tower, East, Gulden, LINAC, Emergency and Bracket Wings).

Findings include, but are not limited to, the following:

a) On 5/25/10 at 10:59AM, a portion of the designated combination fire/smoke barrier between the Main Building and the Original Building (vicinity of Gulden Wing 3rd Floor Treatment Room) was constructed using a non-fire resistance rated door and with a single layer of sheetrock on one side of wall studs. As per concurrent interview with the facility's Director of Engineering, he will ensure that this wall is reconstructed so that it has the required fire resistance rating.

b) On 5/25/10 at 11:10AM, a partially sealed cable penetration was found in the combination fire/smoke barrier between the Original Building and the Main Building (vicinity of 3rd Floor connecting corridor between the Gulden Wing and the Center Wing).

c) On 5/25/10 at 11:40AM, two (2) unsealed cable penetrations were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Pharmacy in the Original Building - Northwest Wing.

d) On 5/26/10 at 9:07AM, an unsealed cable penetration was found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 3rd Floor connecting corridor between the Tower Wing and the Center Wing).

e) On 5/26/10 at 9:43AM, a cable penetration in the fire barrier wall between the Original Building and the Main Building (vicinity of 2nd Floor connecting corridor between the Tower Wing and the Center Wing) was only partially sealed. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed as soon as possible.

f) On 5/26/10 at 10:05AM, an unsealed cable penetration was found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor connecting corridor near Elevator "C").

g) On 5/26/10 at 10:22AM, three (3) unsealed cable penetrations were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Center Wing Security Photo ID Room). As per concurrent interview with the facility's Director of Engineering, these penetrations will be sealed as soon as possible.

h) On 5/26/10 at 10:32AM, three (3) unsealed cable penetrations and an unsealed duct penetration were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Center Wing Kitchen and the East Wing).

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.1.4.1
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Based on observations, the facility did not ensure that buildings containing Health Care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high and provided with complete automatic sprinkler protection.

Findings:

a) On the morning of 5/26/10, observations of the Original Building (Center, North and Northwest wings) revealed that it was of Type II (000) construction and three (3) stories in height. Existing health care occupancies that are of Type II (000) unprotected, non-combustible construction are not permitted to be more than two (2) stories in height even when provided with complete sprinkler protection.

b) On the morning of 5/26/10, two (2) rooftop mechanical rooms in the North Wing of the Original Building and a 4th Floor (attic) elevator machine room in the Northwest Wing were found to lack automatic sprinkler protection.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
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Based on observations, the facility did not ensure that unrated Type 5(000) accessory structures were not placed within ten (10) feet of unprotected window openings in buildings that were not permitted to be combustible.

Findings:

On the morning of 5/24/10, it was noted that a 1-story prefabricated Type 5 (000) building that housed the lounge for the Main Building 1st Floor Emergency Department was approximately two (2) feet from an unprotected window opening to an Emergency Room machine room.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
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Based on observations, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system were constructed to provide at least a ½ -hour fire resistance rating.

Findings:

a) On the morning of 5/25/10, several unsealed cable penetrations, an approximately 3-inch by 4-inch hole, and two (2) unsealed duct penetrations were found in corridor walls of the 3rd Floor of the Main Building - Gulden Wing (e.g., in the vicinity of Rooms #3504, #3522 and #3510).

b) On 5/25/10 it was noted that a small 3-bay patient treatment/holding area in the 1st Floor radiology area was open to the corridor. (The area in question was also not located in a Code conforming suite for Life Safety Code purposes.)

c) On the morning of 5/25/10, several unsealed cable and conduit penetrations and three (3) conduit and one (1) cable penetration that was sealed with a non-fire resistance rated material (i.e., polyurethane expansion foam) were found in corridor walls of the 2nd Floor of the main Building-Brackett Wing (vicinity of Neuropsychologist's Office, Inpatient Rehabilitation Services Office, Room #2412 and Room #2407).

d) On the morning of 5/25/10, a 12-inch by 12-inch hole and several unsealed conduit and cable penetrations were found in corridor walls of the 1st Floor of the Main Building - Brackett Wing (mainly in the vicinity of the "NY Pain Consultants" office suite). In addition, 22 ½-inch by 74 ¾-inch plain glass sidelight was found in the corridor wall near the entrance to the waiting room of the "NY Pain Consultants" office suite.

e) On 5/27/10 it was noted that the 1 East eating area (Servery) that served the employee cafeteria was open to the corridor.
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Based on observations from 5/24/10 - 5/28/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- Two (2) small 6 ft by 3 ft closets in the vicinity of 1st Floor Stair H.

- Pharmacy storeroom #1308.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
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Based on observations from 5/24/10 - 5/28/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

a) In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- Tower Wing electrical closet in the vicinity of #6220 and #5220.

- Tower Wing linen closet in the vicinity of #4211.

- First floor "Harvest Cafe".

- First floor Meditation Room/Chapel.

- 1st floor radiology area CT procedure room. (The area in question was also not located in a Code conforming suite for Life Safety Code purposes.)

- First floor East, Health Library.

-1st floor Brackett Wing mechanical rooms #B-106 and #B-134.

b) In addition, in a few areas, pairs of corridor doors had excessive gaps at their meeting edges and did not resist the passage of smoke. Reference is made to the 1st floor Harvest Café and 1st floor Meditation Room/Chapel .

c) On 5/26/10 at 9:18AM it was noted that the latch on a suite demarcation door from the OR area was malfunctioning. A sheet metal screw prevented the door from positive latching.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
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Based on observations and interview, the facility did not ensure that vision panels and doors in non-fully sprinkler protected smoke compartments were made of fire resistance rated glazing in approved frames.

Findings:

a) On the morning of 5/25/10, an approximately 23-inch by 75-inch plain glass sidelight was found in the corridor wall near the entrance to the waiting room of the "NY Pain Consultants" office suite in the 1st Floor of the Main Building - Brackett Wing.

On 5/25/10 at 11:47AM, three (3) 42-inch by 42-inch vision panels, three 84-inch by 24-inch vision panels, and a glass door in corridor walls in the vicinity of the 1st Floor Main Building - Gulden Wing Admitting Office Suite were made of non-fire resistance rated materials. As per concurrent interview with the facility's Director of Engineering, he will either provide sprinkler protection in this currently non-sprinkler protected smoke compartment or request a waiver.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3, 19.3.6.3.8, 8.2.3.2.2
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1. Based on observations, the facility did not ensure that ventilation shafts between floors were enclosed with at least 1-hour fire resistant construction with fire dampers installed at each direct or ducted opening into or out of the shaft enclosure.

Findings:

a) On 5/25/10 at 9:19AM, an improperly sealed duct outlet (with fire damper) from a ventilation shaft on the 4th Floor of the Tower Wing in the vicinity of Stair E was noted. The ducted outlet from the ventilation shaft enclosure was sealed at the bottom with several intumescent fire-stop bricks. Intumescent products are not listed for use with fire dampers due to the possibility of the expanding brick distorting the duct and causing the fire damper to not close properly.

b) On 5/24/10 at 2:39PM, it was noted that a vertical duct chase (vicinity of the Main Building - Brackett Wing 3rd floor Cardiac Catheterization Unit Waiting Area) was not fully enclosed with fire resistance rated construction. Reference is made to a gap in the enclosure.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 19.5.2.1, NFPA 90A


2. Based on observations and interviews, the facility did not ensure that vertical plumbing and/or electrical penetrations between floors in the Main Building were sealed.

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

a) On 5/24/10 at 2:46PM, four (4) vertical plumbing, one (1) vertical conduit and one (1) vertical duct penetrations in the vicinity of the Main Building - Brackett Wing 2nd Floor Soiled Utility Room were found to have been sealed with non-fire resistance rated polyurethane expansion foam. As per concurrent interview with the facility's Director of Engineering, he will have these vertical penetrations re-sealed with the appropriate fire resistance rated materials.

b) On 5/25/10 at 9:30AM, four (4) unsealed vertical conduit penetrations were found in the Main Building Brackett Wing 1st Floor Machine Room #B-134. As per concurrent interview with the facility's Director of Engineering, he will have these vertical penetrations sealed with the appropriate fire resistance rated materials.

c) On 5/25/10 at 10:28AM, two (2) unsealed vertical conduit penetrations were found in the vicinity of the 3rd Floor corridor of the Main Building - Gulden Wing (near Room #3504).

d) On 5/25/10 at 11:07AM, an approximately 2-inch by 2-inch hole was found in the fire resistance rated walls that enclosed a vertical plumbing chase in the 2nd floor of the Main Building - Gulden Wing (near the Exam Room across from Elevator "A").

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6


3. Based on observations and interview, the facility did not ensure that elevator machine rooms had at least the same fire resistance rating of the elevators they serve (i.e., 1-hour).

Findings:

On 5/25/10 at 9:17AM, an unsealed conduit penetration was found in one of the enclosure walls of Main Building - Brackett Wing 1st Floor elevator machine room #B102. In addition, the door to this room lacked a self-closing device and the fire-resistance rating identification label on the door had been painted over and was no longer legible. As per concurrent interview with the facility's Director of Engineering, he will ensure that this room is provided with at least a 1-hour fire resistance rating.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6, 9.4.3.2, AMSE/ANSI A17.1, Safety Code for Existing Elevators and Escalators
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Based on observations and interviews, the facility did not ensure that vertical plumbing and/or electrical penetrations between floors in the Original Building were sealed.

Findings:

- On 5/26/10 at 9:54AM, four (4) unsealed vertical conduit penetrations were found in the vicinity of the 2nd Floor I.T. Closet in the Original Building - Center Wing.
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Based on observations, the facility did not ensure that all required smoke barrier walls were constructed to provide at least a ½-hour fire resistance rating. Reference is made to small holes and gaps in smoke barrier walls and building service equipment penetrations of smoke barrier walls that were either unsealed or not sealed with a UL Listed Through Penetration Firestop System.

Findings:

a) On 5/24/10 at 2:03PM, two (2) unsealed plumbing and several unsealed cable penetrations were found in a 4th Floor smoke barrier wall in the Main Building - Brackett Wing (vicinity of Room #B404). As per concurrent interview with the facility's Director of Engineering, these penetrations will be sealed.

b) On 5/24/10 at 2:13PM, an unsealed cable penetration and a small hole (½-inch by 1-inch) were found in a smoke barrier wall in the vicinity of the 3rd Floor Main Building - Brackett Wing Cardiac Catheterization Suite.

c) On the afternoon of 5/24/10 a 3-inch by 3-inch hole and a gap sealed with only mineral wool insulation was noted in a portion of a smoke barrier on the 6th Floor of the Tower Wing (vicinity toilet room #6225).

d) On 5/25/10 at 10:23AM, an unsealed cable penetration was found above the cross-corridor smoke barrier door in the 3rd Floor smoke barrier between the Main Building Bracket Wing and Gulden Wing.

e) On the morning of 5/25/10 it was noted that building service equipment penetrations above cross corridor smoke barriers doors on the 4th Floor of the Tower Wing (vicinity Room #4226, West wall) were sealed with mineral wool insulation and / or joint compound. Penetrations of smoke barrier walls shall be sealed with UL Listed Through Penetration Firestop Systems.

f) On the morning of 5/25/10 a 6-inch by 6-inch hole was noted in a smoke barrier wall (toilet room vicinity #T 324) on the 3rd Floor of the Tower Wing.

g) On 5/25/10 at 12:01PM, an approximately 12-inch by 12-inch hole was found in a 1st Floor smoke barrier wall in the vicinity of the Psychiatry Office in the Main Building - Gulden Wing.

h) On 5/26/10 at 10:00AM, an improperly sealed cable penetration was noted in a smoke barrier wall in the 2nd Floor maternity area. The space around the cable penetration had been sealed with a firestopping compound without the use of the required backing material. Upon drying/shrinking the firestopping compound had pulled away from the opening and the opening was no longer sealed.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.7.3
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1. Based on observations, the facility did not ensure that unsprinklered hazardous areas were separated from all other spaces by at least 1-hour fire resistance rated partitions with all door openings protected with at least ¾-hour self closing, positive latching fire doors.

Findings:

a) On 5/25/10 at 8:45AM, a 4-inch by 4-inch hole was noted in the wall separating the 5th Floor Tower Wing Clean Utility Room (i.e., storage room in excess of 50 sq. ft.) and the adjacent pantry.

b) On 5/25/10 at 9:34AM, the door to the 1st Floor Main Building - Brackett Wing electrical room #B135 lacked a self-closing device.

c) On 5/25/10 at 10:27AM, the door to a 3rd Floor Main Building - Gulden Wing storage room (near Room #3506) lacked a self-closing device.

d) On the afternoon of 5/25/10, a 6-inch by 6-inch hole was noted in the wall separating the 4th Floor Tower Wing Clean Utility Room (i.e., storage room in excess of 50 sq. ft.) and the adjacent pantry (vicinity Room #4205).

e) On the morning of 5/27/10 it was noted that the boiler/mechanical room in the vicinity of Stair L was not separated from surrounding spaces by at least 1-hour construction. Reference is made to a 6-inch by 8-inch opening to the adjacent Stair L exit passageway and a 2-inch by 2-inch opening to an adjacent food storage room.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1


2. Based on observations and interviews, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant, self closing, positive latching fire doors.

Findings:

a) On 5/24/10 at 2:10PM, the door to a Main Building - Bracket Wing 3rd floor Clean Utility Room (e.g., Room #B317) was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

b) On 5/27/10 at 11:18AM, the door to a Main Building-East Wing 1st Floor office supply storage room (in the vicinity of the Board Room) was found to lack a self-closing device.

c) On 5/27/10 at 11:28AM, the door to the Main Building-East wing 1st Floor Medical Records Room was found to lack a self-closing device.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
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Based on observations and interviews, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant, self closing, positive latching fire doors.

Findings:

a) On 5/26/10 at 10:15AM, the door to a Original Building - Center Wing 1st Floor mechanical/storage room (i.e., the "Pipe Room") was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

b) On 5/26/10 at 10:49AM, two (2) unsealed conduit penetrations were found in a wall of a Original Building - North Wing 1st Floor mechanical room (near the kitchen area). As per concurrent interview with the facility's Director of Engineering, he will have the penetrations sealed as soon as possible.

c) On 5/27/10 at 8:31AM, the door to a Original Building - North Wing 1st Floor storage room (i.e., the "Housekeeping Storage #1") was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
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Based on observations, the hospital laboratory area was not separated from surrounding spaces with at least 1-hour construction.

Findings:

On the morning of 5/26/10, a 6-inch by 6-inch opening was noted around a ventilation duct that penetrated the corridor wall in the vicinity of the main entrance door to the lab.

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: 10-3
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1. Based on observations the facility did not ensure that all exit passageways were enclosed with at least 1-hour construction. Reference is made to an unsealed wire penetration in the 2nd Floor level exit passageway connecting Stair E of the Main Building Tower Wing and Stair M.

Findings:

a) On 5/27, 2010 at 12 Noon, an unsealed cable with a 1-inch annular space around it was noted in the above mentioned exit passageway.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1


2. Based on observations and interviews, the facility did not ensure that all exit staircases were enclosed with at least 1-hour construction.

Findings:

a) On 5/25/10 at 12:07PM, an unsealed conduit penetration and a partially sealed plumbing penetration were found in the 1st Floor stair enclosure wall that serves Exit Stair J in the Main Building - Gulden Wing. As per concurrent interview with the facility's Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
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Based on observations and interviews, the facility did not ensure that all exit staircases were enclosed with at least 1-hour construction.

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

a) On 5/26/10 at 9:30AM, two (2) approximately 28-inch long by 2-inch wide unsealed openings were found on either side of a duct penetration found in an stair enclosure wall that serves Exit Stair H in the vicinity of the 4th Floor (attic) Original Building - Northwest Wing mechanical room. In addition, the duct that penetrates this exit stair enclosure did not serve the stair.

c) On 5/26/10 at 10:00AM, an unsealed cable penetration was found in an enclosure wall that serves Exit Stair O (2nd Floor of the Original Building - North Wing).

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
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Based on observations and interview, the facility did not ensure that openings into exit stair enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and for egress from the enclosure.

Findings:

a) On 5/26/10 at 9:25AM, a 2nd Floor Original Building - Northwest Wing housekeeping storage room was found to open directly into Exit Stair H. As per concurrent interview with the facility's Director of Engineering, he will probably submit a waiver request for this issue.

b) On 5/26/10 at 9:26AM, a 3rd Floor Original Building - Northwest Wing housekeeping storage room was found to open directly into Exit Stair H.

c) On 5/26/10 at 9:28AM, a 4th Floor (attic) Original Building - Northwest Wing mechanical room was found to open directly into Exit Stair H.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
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Based on observations the facility did not ensure that openings in stair enclosures were limited to those necessary to access enclosure from normally occupied spaces and corridors.

Findings:

Access to a 2nd floor Southwest machine room was through the G Stairwell.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 7.1.3.2.1
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Based on observations and interview, exit access and exit doors were provided with electronic locks that unlocked upon activation of the fire alarm system. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients. NFPA 101-2000 prohibits such locking devices for security purposes, and it was not until the 2009 Edition (which is not referenced by CMS, NYS-DOH or JCAHO) that, with certain provisions, that locking devices for security purposes were provided.

Findings:

- On 5/25/10 at 10:41AM, it was noted that a pair of cross-corridor smoke barrier/exit access doors on the 3rd Floor between the Main Building - Gulden Wing and the Original Building - Center Wing were provided with an electronic locking device that was part of an infant abduction system.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
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Based on observations and interview, exit access and exit doors were provided with electronic locks that unlocked upon activation of the fire alarm system. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients. NFPA 101-2000 prohibits such locking devices for security purposes, and it was not until the 2009 Edition (which is not referenced by CMS, NYS-DOH or JCAHO) that, with certain provisions, that locking devices for security purposes were provided.

Findings:

a) On 5/24/10 at 1:09PM, it was noted that an exit door in the vicinity of the 1st Floor Board Room was provided with a swipe card de-activated electronic lock.

b) On the morning of 5/25/10 it was noted that the exit discharge door to Stairwell F (Tower Wing) was provided with an electronic locking device. Concurrent staff interview indicated the lock was de-activated by the fire alarm system and was slated to be replaced by a conforming delayed egress lock.

c) On 5/25/10 at 10:20AM, it was noted that a pair of cross-corridor smoke barrier/exit access doors on the 3rd Floor between the Main Building Brackett Wing and the Gulden Wing were provided with a swipe card de-activated electronic lock.

d) On 5/26/10 at 10:15AM, it was noted that a pair of corridor control doors in the 2nd Floor maternity area was provided with an electronic locking device that was part of an infant abduction system. Concurrent staff interview indicated the lock was de-activated by the fire alarm system

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
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Based on observations and interview, the facility did not exit access aisles and corridors that serve patient sleeping rooms were provided with a clear and unobstructed width of at least 48-inches.

Findings:

On 5/25/10 at 11:27AM, the door to an electrical closet in the exit access aisle that serves Room #2307 on the 2nd Floor of the Main Building - Gulden Wing was found to reduce the clear width of this aisle from 48-inches to 17-inches when opened. As per concurrent interview with the facility's Director of Engineering, he will probably request a waiver for this condition.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.3.3
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Based on record review and interview, the facility's written fire plan called for the use of smoke barriers for the staged evacuation of all areas but not all floors in the hospital were provided with smoke barriers.

Findings:

a) On the afternoon of 5/27/10, review of the facility's horizontal and vertical evacuation procedures contained in the fire plan revealed that the plan called for the use of smoke barriers in staged (horizontal) evacuation of the hospital. The 1st Floor of the Main Building - Brackett Wing was not provided with any smoke barrier(s) to divide this floor into one or more smoke compartments. Due to the lack of smoke barriers on this floor it would be required to be immediately evacuated in the event of a fire.

b) On 5/27/10 at 3:01PM, the issues concerning the lack of a smoke barrier and the need to conduct an immediate evacuation of the 1st floor of the Main Building - Brackett Wing in the event of a fire was brought to the attention of the facility's Director of Engineering and the Director of Safety. They both said that rather than having this area conduct an immediate evacuation that they will install a smoke barrier of this floor.

42CFR 483.70(a)(1), NFPA 101-2000: 19.7.1.1, 19.7.2
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Based on observations, the facility did not ensure that sprinkler systems were inspected, tested, or maintained in accordance with all of the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

a) On 5/24/10 at 11:42AM, a Holly tree was found growing directly in front of and blocking fire service access to a Main Building sprinkler system Fire Department connection (vicinity of the Maternity Unit). As per concurrent interview with the facility's Director of Engineering, the tree and any other bushes that obstruct access to the Fire Department connection will be removed immediately.

b) On 5/24/10 at 11:48AM, several bushes were found growing directly in front of and blocking fire service access to a Main Building combination sprinkler system/standpipe system Fire Department connection (vicinity of the Lab Unit). As per concurrent interview with the facility's Director of Engineering, the tree and any other bushes that obstruct access to the Fire Department connection will be removed immediately.

c) On the afternoon of 5/27/10, review of the sprinkler system maintenance, inspection, and testing records for the facility revealed that sprinkler system pressure gauges had not been calibrated or replaced within the last five (5) years, that sprinkler system alarm valves had not been inspected within the last five (5) years, and that sprinkler system check vales had not been inspected within the last five (5) years.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.5.1, 9.7.5, NFPA 25-1998: 2-1, 9-1, 9-7
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Based on observations and interview, the facility did not ensure that all portable fire extinguishers were visually inspected at least once per month and maintained in good repair.

Findings:

On 5/26/10 at 8:35AM, a portable fire extinguisher in the Original Building - North Wing rooftop mechanical room was found to lack a monthly visual inspection record tag and the pressure gauge status indicator was on "recharge". As per concurrent interview with the facility's Director of Engineering, he would have this fire extinguisher immediately removed from service and replaced.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 4-3
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Based on observations, the facility did not ensure that oxidizing gasses (e.g., nitrous oxide) were properly stored in accordance with NFPA 99-1999.

Findings:

On 5/24/10 at 2:30PM, three (3) unsecured nitrous oxide cylinders were noted in the 3rd Floor Oxygen Storage Room #B338 of the Main Building - Brackett Wing.

42CFR 483.70(a)(1), NFPA 99 - 1999: 8-3.1.11
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Based on observations, the facility did not ensure that oxidizing gasses (e.g., oxygen) and flammable non-medical gasses (i.e., acetylene, propane) were properly stored in accordance with NFPA 99-1999.

Findings:

a) On 5/24/10 at 12:30PM improperly stored gases were noted in the exterior fenced in enclosure in the vicinity of the "O" exit stairwell. Reference is made to two (2) propane containers and one (1) acetylene cylinder that were stored twelve - twenty-four (12) - (24) inches from an oxygen cylinder. Oxidizing gases shall be separated from incompatible materials by a distance of twenty (20) feet in unsprinklered storage locations, five (5) feet in sprinklered locations or by placement in a one-half (½) hour rated cabinet.

- On 5/24/10 at 12:30PM unsecured freestanding compressed gas cylinders were noted in a different portion of the above mentioned storage area. Reference is made to an unsecured H size oxygen cylinder, fifteen (15) unsecured nitrous oxide cylinders and six (6) carbon dioxide cylinders.

42CFR 483.70(a)(1), NFPA 99 - 1999: 8-3.1.11
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1. Based on observations and record (i.e., panelboard schedule) review the Main Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System.

For example:

- Emergency power panelboard LP-1WE (Location: Mech/Elect. Room 1st Floor Room #1408 Bracket Wing) served both sewage pumps (Equipment System) and a fire alarm control panel (Emergency System - Life Safety Branch).

- Emergency power panelboard ELS-1L (Location: Labor and Delivery) served both a sump pump (Equipment System) and a medical gas alarm (Emergency System - Life Safety Branch).

b) The wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

For example:

- Emergency power panelboard LP-1WE (Location: Mech/Elect. Room 1st Floor, Room #1408 Bracket Wing) served both a fire alarm control panel (Emergency System - Life Safety Branch) and a 3rd Floor Nursing Station (Emergency System - Critical Branch).

- Emergency power panelboard ELS-1L (Location: Labor and Delivery) served both a medical gas alarm (Emergency System - Life Safety Branch) and a nurse call panel (Emergency System - Critical Branch).

- Emergency power panelboard LP-1ME (Location: Electric closet #1017C, East Wing) served both a fire alarm panel (Emergency System - Life Safety Branch) and a receptacle for a security camera (Emergency System - Critical Branch).

- Emergency power panelboard GBE (Location: Same Day Surgery, 1st Floor Gulden Wing) served both exit access lighting (Emergency System - Life Safety Branch) and receptacles in patient rooms (Emergency System - Critical Branch).

- Emergency power panelboard LP-1PE (Location: Medical Records, 1st Floor East Wing) served both exit lights (Emergency System - Life Safety Branch) and a Board Room receptacle (Emergency System - Critical Branch).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


2. Based on observations, all ramps in the means of egress were not provided with handrails.

Findings:

a) On 5/24/10 at 12:06PM, it was noted that a ramp to grade at the exit discharge of an exit serving the Information Services (Main Building) area was not provided with handrails.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.6, 7.2.5


3. Based on observations the facility did not ensure that the arrangement of all means of egress in the Main Building was in accordance with NFPA 101-2000: 19.2.5.

Findings:

a) On the morning of 5/27/10, it was noted that a required means of exit access was through the Main Building 1st Floor cafeteria seating area. Corridors shall provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies.

b) Exit access on the 3rd Floor of the East Wing (i.e., ICU area) required suite to suite travel. Although suite to suite travel is permitted under certain conditions by NFPA 101-2006, neither CMS nor NYS has adopted the 2006 Edition of NFPA 101.

c) Exit access on the 1st floor "Fast Track" Emergency Department (ED) area required suite to suite travel through the adjacent ED suite. Although suite to suite travel is permitted under certain conditions by NFPA 101-2006, neither CMS nor NYS has adopted the 2006 Edition of NFPA 101.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5.9, 19.2.5.2, 19.2.5.8


4. Based on observations the facility did not ensure that doors in the means of egress that served rooms or spaces with an occupant load in excess of fifty (50) persons swung in the direction of exit travel.

Findings:

a) On the morning of 5/24/10, it was noted that the doors from the Main Building Board Room to the adjacent corridor did not swing in the direction of exit travel. The calculated occupant load of the room was in excess of fifty (50) persons (i.e., seventy-five (75) persons) and on 5/27/10 at 8:52AM, forty-six (46) non-fixed chairs were noted in the room.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.1.2, 7.2.1.4.2

1. Based on observations and record (i.e., panelboard schedule) review the Original Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example, on 5/26/10 at 9:05AM, it was noted that Emergency Power Panel 3BE in the 3rd Floor of the Original Building - Center Wing served items from the Emergency System - Life Safety Branch (i.e., Circuit 32 Corridor lights), Emergency System - Critical Branch (i.e., Circuit #17 Receptacles at Nurses Station) and the Equipment System (i.e., Circuit #1 Air Handler).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


2. Based on observations and interview, the facility did not ensure that all sleeping rooms (i.e., Lodging and Rooming House occupancies) that would require a smoke detector were provided with one.

Findings:

a) On the morning of 5/26/10, eleven (11) out of twelve (12) on-call physician and physician assistant sleeping rooms located on 3rd Floor of the Original Building - Northwest Wing (e.g. Rooms #3314, #3315 and #3318) were found to lack required smoke detectors in the room.

b) On 5/26/10 at 9:15AM, interview with the facility's Director of Engineering revealed that he was not aware that the on-call sleeping rooms would require smoke detectors. He said he would inform his supervisor of this issue.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.2, 6.1.4, 26.3.3.5
.

Based on observations and interview, the facility did not ensure that temporary wiring and lighting fixtures were removed upon the completion of construction.

Findings:

On 5/26/10 at 8:53AM, temporary electrical wiring and lighting fixture were found above the suspended ceiling in the Original Building - Center Wing (in the vicinity of a 3rd Floor connecting corridor between this building an the Main Building - Tower Wing). As per concurrent interview with the facility's Director of Engineering, he will ensure that the temporary wiring is no longer energized and will attempt to remove it.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 305-3(d)

Based on observations and interviews, the facility did not ensure that a 2-hour fire barrier wall was provided to separate the 3-story, not fully sprinklered, Type 11 (000) Original Building (i.e., Center, North and Northwest Wings) from the Main Building (i.e., Tower, East, Gulden, LINAC, Emergency and Bracket Wings).

Findings include, but are not limited to, the following:

a) On 5/25/10 at 10:59AM, a portion of the designated combination fire/smoke barrier between the Main Building and the Original Building (vicinity of Gulden Wing 3rd Floor Treatment Room) was constructed using a non-fire resistance rated door and with a single layer of sheetrock on one side of wall studs. As per concurrent interview with the facility's Director of Engineering, he will ensure that this wall is reconstructed so that it has the required fire resistance rating.

b) On 5/25/10 at 11:10AM, a partially sealed cable penetration was found in the combination fire/smoke barrier between the Original Building and the Main Building (vicinity of 3rd Floor connecting corridor between the Gulden Wing and the Center Wing).

c) On 5/25/10 at 11:40AM, two (2) unsealed cable penetrations were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Pharmacy in the Original Building - Northwest Wing.

d) On 5/26/10 at 9:07AM, an unsealed cable penetration was found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 3rd Floor connecting corridor between the Tower Wing and the Center Wing).

e) On 5/26/10 at 9:43AM, a cable penetration in the fire barrier wall between the Original Building and the Main Building (vicinity of 2nd Floor connecting corridor between the Tower Wing and the Center Wing) was only partially sealed. As per concurrent interview with the facility's Director of Engineering, this penetration will be sealed as soon as possible.

f) On 5/26/10 at 10:05AM, an unsealed cable penetration was found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor connecting corridor near Elevator "C").

g) On 5/26/10 at 10:22AM, three (3) unsealed cable penetrations were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Center Wing Security Photo ID Room). As per concurrent interview with the facility's Director of Engineering, these penetrations will be sealed as soon as possible.

h) On 5/26/10 at 10:32AM, three (3) unsealed cable penetrations and an unsealed duct penetration were found in a combination fire barrier/smoke barrier wall between the Original Building and the Main Building (vicinity of 1st Floor Center Wing Kitchen and the East Wing).

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.1.4.1
.

Based on observations, the facility did not ensure that buildings containing Health Care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high and provided with complete automatic sprinkler protection.

Findings:

a) On the morning of 5/26/10, observations of the Original Building (Center, North and Northwest wings) revealed that it was of Type II (000) construction and three (3) stories in height. Existing health care occupancies that are of Type II (000) unprotected, non-combustible construction are not permitted to be more than two (2) stories in height even when provided with complete sprinkler protection.

b) On the morning of 5/26/10, two (2) rooftop mechanical rooms in the North Wing of the Original Building and a 4th Floor (attic) elevator machine room in the Northwest Wing were found to lack automatic sprinkler protection.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
.

Based on observations, the facility did not ensure that unrated Type 5(000) accessory structures were not placed within ten (10) feet of unprotected window openings in buildings that were not permitted to be combustible.

Findings:

On the morning of 5/24/10, it was noted that a 1-story prefabricated Type 5 (000) building that housed the lounge for the Main Building 1st Floor Emergency Department was approximately two (2) feet from an unprotected window opening to an Emergency Room machine room.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
.

Based on observations, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system were constructed to provide at least a ½ -hour fire resistance rating.

Findings:

a) On the morning of 5/25/10, several unsealed cable penetrations, an approximately 3-inch by 4-inch hole, and two (2) unsealed duct penetrations were found in corridor walls of the 3rd Floor of the Main Building - Gulden Wing (e.g., in the vicinity of Rooms #3504, #3522 and #3510).

b) On 5/25/10 it was noted that a small 3-bay patient treatment/holding area in the 1st Floor radiology area was open to the corridor. (The area in question was also not located in a Code conforming suite for Life Safety Code purposes.)

c) On the morning of 5/25/10, several unsealed cable and conduit penetrations and three (3) conduit and one (1) cable penetration that was sealed with a non-fire resistance rated material (i.e., polyurethane expansion foam) were found in corridor walls of the 2nd Floor of the main Building-Brackett Wing (vicinity of Neuropsychologist's Office, Inpatient Rehabilitation Services Office, Room #2412 and Room #2407).

d) On the morning of 5/25/10, a 12-inch by 12-inch hole and several unsealed conduit and cable penetrations were found in corridor walls of the 1st Floor of the Main Building - Brackett Wing (mainly in the vicinity of the "NY Pain Consultants" office suite). In addition, 22 ½-inch by 74 ¾-inch plain glass sidelight was found in the corridor wall near the entrance to the waiting room of the "NY Pain Consultants" office suite.

e) On 5/27/10 it was noted that the 1 East eating area (Servery) that served the employee cafeteria was open to the corridor.
.

Based on observations from 5/24/10 - 5/28/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- Two (2) small 6 ft by 3 ft closets in the vicinity of 1st Floor Stair H.

- Pharmacy storeroom #1308.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
.

Based on observations from 5/24/10 - 5/28/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

a) In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- Tower Wing electrical closet in the vicinity of #6220 and #5220.

- Tower Wing linen closet in the vicinity of #4211.

- First floor "Harvest Cafe".

- First floor Meditation Room/Chapel.

- 1st floor radiology area CT procedure room. (The area in question was also not located in a Code conforming suite for Life Safety Code purposes.)

- First floor East, Health Library.

-1st floor Brackett Wing mechanical rooms #B-106 and #B-134.

b) In addition, in a few areas, pairs of corridor doors had excessive gaps at their meeting edges and did not resist the passage of smoke. Reference is made to the 1st floor Harvest Café and 1st floor Meditation Room/Chapel .

c) On 5/26/10 at 9:18AM it was noted that the latch on a suite demarcation door from the OR area was malfunctioning. A sheet metal screw prevented the door from positive latching.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
.

Based on observations and interview, the facility did not ensure that vision panels and doors in non-fully sprinkler protected smoke compartments were made of fire resistance rated glazing in approved frames.

Findings:

a) On the morning of 5/25/10, an approximately 23-inch by 75-inch plain glass sidelight was found in the corridor wall near the entrance to the waiting room of the "NY Pain Consultants" office suite in the 1st Floor of the Main Building - Brackett Wing.

On 5/25/10 at 11:47AM, three (3) 42-inch by 42-inch vision panels, three 84-inch by 24-inch vision panels, and a glass door in corridor walls in the vicinity of the 1st Floor Main Building - Gulden Wing Admitting Office Suite were made of non-fire resistance rated materials. As per concurrent interview with the facility's Director of Engineering, he will either provide sprinkler protection in this currently non-sprinkler protected smoke compartment or request a waiver.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3, 19.3.6.3.8, 8.2.3.2.2
.

1. Based on observations, the facility did not ensure that ventilation shafts between floors were enclosed with at least 1-hour fire resistant construction with fire dampers installed at each direct or ducted opening into or out of the shaft enclosure.

Findings:

a) On 5/25/10 at 9:19AM, an improperly sealed duct outlet (with fire damper) from a ventilation shaft on the 4th Floor of the Tower Wing in the vicinity of Stair E was noted. The ducted outlet from the ventilation shaft enclosure was sealed at the bottom with several intumescent fire-stop bricks. Intumescent products are not listed for use with fire dampers due to the possibility of the expanding brick distorting the duct and causing the fire damper to not close properly.

b) On 5/24/10 at 2:39PM, it was noted that a vertical duct chase (vicinity of the Main Building - Brackett Wing 3rd floor Cardiac Catheterization Unit Waiting Area) was not fully enclosed with fire resistance rated construction. Reference is made to a gap in the enclosure.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 19.5.2.1, NFPA 90A


2. Based on observations and interviews, the facility did not ensure that vertical plumbing and/or electrical penetrations between floors in the Main Building were sealed.

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

a) On 5/24/10 at 2:46PM, four (4) vertical plumbing, one (1) vertical conduit and one (1) vertical duct penetrations in the vicinity of the Main Building - Brackett Wing 2nd Floor Soiled Utility Room were found to have been sealed with non-fire resistance rated polyurethane expansion foam. As per concurrent interview with the facility's Director of Engineering, he will have these vertical penetrations re-sealed with the appropriate fire resistance rated materials.

b) On 5/25/10 at 9:30AM, four (4) unsealed vertical conduit penetrations were found in the Main Building Brackett Wing 1st Floor Machine Room #B-134. As per concurrent interview with the facility's Director of Engineering, he will have these vertical penetrations sealed with the appropriate fire resistance rated materials.

c) On 5/25/10 at 10:28AM, two (2) unsealed vertical conduit penetrations were found in the vicinity of the 3rd Floor corridor of the Main Building - Gulden Wing (near Room #3504).

d) On 5/25/10 at 11:07AM, an approximately 2-inch by 2-inch hole was found in the fire resistance rated walls that enclosed a vertical plumbing chase in the 2nd floor of the Main Building - Gulden Wing (near the Exam Room across from Elevator "A").

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6


3. Based on observations and interview, the facility did not ensure that elevator machine rooms had at least the same fire resistance rating of the elevators they serve (i.e., 1-hour).

Findings:

On 5/25/10 at 9:17AM, an unsealed conduit penetration was found in one of the enclosure walls of Main Building - Brackett Wing 1st Floor elevator machine room #B102. In addition, the door to this room lacked a self-closing device and the fire-resistance rating identification label on the door had been painted over and was no longer legible. As per concurrent interview with the facility's Director of Engineering, he will ensure that this room is provided with at least a 1-hour fire resistance rating.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6, 9.4.3.2, AMSE/ANSI A17.1, Safety Code for Existing Elevators and Escalators
.

Based on observations and interviews, the facility did not ensure that vertical plumbing and/or electrical penetrations between floors in the Original Building were sealed.

Findings:

- On 5/26/10 at 9:54AM, four (4) unsealed vertical conduit penetrations were found in the vicinity of the 2nd Floor I.T. Closet in the Original Building - Center Wing.
.

Based on observations, the facility did not ensure that all required smoke barrier walls were constructed to provide at least a ½-hour fire resistance rating. Reference is made to small holes and gaps in smoke barrier walls and building service equipment penetrations of smoke barrier walls that were either unsealed or not sealed with a UL Listed Through Penetration Firestop System.

Findings:

a) On 5/24/10 at 2:03PM, two (2) unsealed plumbing and several unsealed cable penetrations were found in a 4th Floor smoke barrier wall in the Main Building - Brackett Wing (vicinity of Room #B404). As per concurrent interview with the facility's Director of Engineering, these penetrations will be sealed.

b) On 5/24/10 at 2:13PM, an unsealed cable penetration and a small hole (½-inch by 1-inch) were found in a smoke barrier wall in the vicinity of the 3rd Floor Main Building - Brackett Wing Cardiac Catheterization Suite.

c) On the afternoon of 5/24/10 a 3-inch by 3-inch hole and a gap sealed with only mineral wool insulation was noted in a portion of a smoke barrier on the 6th Floor of the Tower Wing (vicinity toilet room #6225).

d) On 5/25/10 at 10:23AM, an unsealed cable penetration was found above the cross-corridor smoke barrier door in the 3rd Floor smoke barrier between the Main Building Bracket Wing and Gulden Wing.

e) On the morning of 5/25/10 it was noted that building service equipment penetrations above cross corridor smoke barriers doors on the 4th Floor of the Tower Wing (vicinity Room #4226, West wall) were sealed with mineral wool insulation and / or joint compound. Penetrations of smoke barrier walls shall be sealed with UL Listed Through Penetration Firestop Systems.

f) On the morning of 5/25/10 a 6-inch by 6-inch hole was noted in a smoke barrier wall (toilet room vicinity #T 324) on the 3rd Floor of the Tower Wing.

g) On 5/25/10 at 12:01PM, an approximately 12-inch by 12-inch hole was found in a 1st Floor smoke barrier wall in the vicinity of the Psychiatry Office in the Main Building - Gulden Wing.

h) On 5/26/10 at 10:00AM, an improperly sealed cable penetration was noted in a smoke barrier wall in the 2nd Floor maternity area. The space around the cable penetration had been sealed with a firestopping compound without the use of the required backing material. Upon drying/shrinking the firestopping compound had pulled away from the opening and the opening was no longer sealed.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.7.3
.

1. Based on observations, the facility did not ensure that unsprinklered hazardous areas were separated from all other spaces by at least 1-hour fire resistance rated partitions with all door openings protected with at least ¾-hour self closing, positive latching fire doors.

Findings:

a) On 5/25/10 at 8:45AM, a 4-inch by 4-inch hole was noted in the wall separating the 5th Floor Tower Wing Clean Utility Room (i.e., storage room in excess of 50 sq. ft.) and the adjacent pantry.

b) On 5/25/10 at 9:34AM, the door to the 1st Floor Main Building - Brackett Wing electrical room #B135 lacked a self-closing device.

c) On 5/25/10 at 10:27AM, the door to a 3rd Floor Main Building - Gulden Wing storage room (near Room #3506) lacked a self-closing device.

d) On the afternoon of 5/25/10, a 6-inch by 6-inch hole was noted in the wall separating the 4th Floor Tower Wing Clean Utility Room (i.e., storage room in excess of 50 sq. ft.) and the adjacent pantry (vicinity Room #4205).

e) On the morning of 5/27/10 it was noted that the boiler/mechanical room in the vicinity of Stair L was not separated from surrounding spaces by at least 1-hour construction. Reference is made to a 6-inch by 8-inch opening to the adjacent Stair L exit passageway and a 2-inch by 2-inch opening to an adjacent food storage room.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1


2. Based on observations and interviews, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant, self closing, positive latching fire doors.

Findings:

a) On 5/24/10 at 2:10PM, the door to a Main Building - Bracket Wing 3rd floor Clean Utility Room (e.g., Room #B317) was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

b) On 5/27/10 at 11:18AM, the door to a Main Building-East Wing 1st Floor office supply storage room (in the vicinity of the Board Room) was found to lack a self-closing device.

c) On 5/27/10 at 11:28AM, the door to the Main Building-East wing 1st Floor Medical Records Room was found to lack a self-closing device.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
.

Based on observations and interviews, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant, self closing, positive latching fire doors.

Findings:

a) On 5/26/10 at 10:15AM, the door to a Original Building - Center Wing 1st Floor mechanical/storage room (i.e., the "Pipe Room") was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

b) On 5/26/10 at 10:49AM, two (2) unsealed conduit penetrations were found in a wall of a Original Building - North Wing 1st Floor mechanical room (near the kitchen area). As per concurrent interview with the facility's Director of Engineering, he will have the penetrations sealed as soon as possible.

c) On 5/27/10 at 8:31AM, the door to a Original Building - North Wing 1st Floor storage room (i.e., the "Housekeeping Storage #1") was found to lack a self-closing device. As per concurrent interview with the facility's Director of Engineering, the door to this room will be provided with a self-closing device as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
.

Based on observations, the hospital laboratory area was not separated from surrounding spaces with at least 1-hour construction.

Findings:

On the morning of 5/26/10, a 6-inch by 6-inch opening was noted around a ventilation duct that penetrated the corridor wall in the vicinity of the main entrance door to the lab.

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: 10-3
.

1. Based on observations the facility did not ensure that all exit passageways were enclosed with at least 1-hour construction. Reference is made to an unsealed wire penetration in the 2nd Floor level exit passageway connecting Stair E of the Main Building Tower Wing and Stair M.

Findings:

a) On 5/27, 2010 at 12 Noon, an unsealed cable with a 1-inch annular space around it was noted in the above mentioned exit passageway.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1


2. Based on observations and interviews, the facility did not ensure that all exit staircases were enclosed with at least 1-hour construction.

Findings:

a) On 5/25/10 at 12:07PM, an unsealed conduit penetration and a partially sealed plumbing penetration were found in the 1st Floor stair enclosure wall that serves Exit Stair J in the Main Building - Gulden Wing. As per concurrent interview with the facility's Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
.

Based on observations and interviews, the facility did not ensure that all exit staircases were enclosed with at least 1-hour construction.

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

a) On 5/26/10 at 9:30AM, two (2) approximately 28-inch long by 2-inch wide unsealed openings were found on either side of a duct penetration found in an stair enclosure wall that serves Exit Stair H in the vicinity of the 4th Floor (attic) Original Building - Northwest Wing mechanical room. In addition, the duct that penetrates this exit stair enclosure did not serve the stair.

c) On 5/26/10 at 10:00AM, an unsealed cable penetration was found in an enclosure wall that serves Exit Stair O (2nd Floor of the Original Building - North Wing).

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
.

Based on observations and interview, the facility did not ensure that openings into exit stair enclosures were limited to those necessary for access to the enclosure from normally occupied spaces and for egress from the enclosure.

Findings:

a) On 5/26/10 at 9:25AM, a 2nd Floor Original Building - Northwest Wing housekeeping storage room was found to open directly into Exit Stair H. As per concurrent interview with the facility's Director of Engineering, he will probably submit a waiver request for this issue.

b) On 5/26/10 at 9:26AM, a 3rd Floor Original Building - Northwest Wing housekeeping storage room was found to open directly into Exit Stair H.

c) On 5/26/10 at 9:28AM, a 4th Floor (attic) Original Building - Northwest Wing mechanical room was found to open directly into Exit Stair H.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2.1
.

Based on observations the facility did not ensure that openings in stair enclosures were limited to those necessary to access enclosure from normally occupied spaces and corridors.

Findings:

Access to a 2nd floor Southwest machine room was through the G Stairwell.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 7.1.3.2.1
.

Based on observations and interview, exit access and exit doors were provided with electronic locks that unlocked upon activation of the fire alarm system. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients. NFPA 101-2000 prohibits such locking devices for security purposes, and it was not until the 2009 Edition (which is not referenced by CMS, NYS-DOH or JCAHO) that, with certain provisions, that locking devices for security purposes were provided.

Findings:

- On 5/25/10 at 10:41AM, it was noted that a pair of cross-corridor smoke barrier/exit access doors on the 3rd Floor between the Main Building - Gulden Wing and the Original Building - Center Wing were provided with an electronic locking device that was part of an infant abduction system.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
.

Based on observations and interview, exit access and exit doors were provided with electronic locks that unlocked upon activation of the fire alarm system. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients. NFPA 101-2000 prohibits such locking devices for security purposes, and it was not until the 2009 Edition (which is not referenced by CMS, NYS-DOH or JCAHO) that, with certain provisions, that locking devices for security purposes were provided.

Findings:

a) On 5/24/10 at 1:09PM, it was noted that an exit door in the vicinity of the 1st Floor Board Room was provided with a swipe card de-activated electronic lock.

b) On the morning of 5/25/10 it was noted that the exit discharge door to Stairwell F (Tower Wing) was provided with an electronic locking device. Concurrent staff interview indicated the lock was de-activated by the fire alarm system and was slated to be replaced by a conforming delayed egress lock.

c) On 5/25/10 at 10:20AM, it was noted that a pair of cross-corridor smoke barrier/exit access doors on the 3rd Floor between the Main Building Brackett Wing and the Gulden Wing were provided with a swipe card de-activated electronic lock.

d) On 5/26/10 at 10:15AM, it was noted that a pair of corridor control doors in the 2nd Floor maternity area was provided with an electronic locking device that was part of an infant abduction system. Concurrent staff interview indicated the lock was de-activated by the fire alarm system

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
.

Based on observations and interview, the facility did not exit access aisles and corridors that serve patient sleeping rooms were provided with a clear and unobstructed width of at least 48-inches.

Findings:

On 5/25/10 at 11:27AM, the door to an electrical closet in the exit access aisle that serves Room #2307 on the 2nd Floor of the Main Building - Gulden Wing was found to reduce the clear width of this aisle from 48-inches to 17-inches when opened. As per concurrent interview with the facility's Director of Engineering, he will probably request a waiver for this condition.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.3.3
.

Based on record review and interview, the facility's written fire plan called for the use of smoke barriers for the staged evacuation of all areas but not all floors in the hospital were provided with smoke barriers.

Findings:

a) On the afternoon of 5/27/10, review of the facility's horizontal and vertical evacuation procedures contained in the fire plan revealed that the plan called for the use of smoke barriers in staged (horizontal) evacuation of the hospital. The 1st Floor of the Main Building - Brackett Wing was not provided with any smoke barrier(s) to divide this floor into one or more smoke compartments. Due to the lack of smoke barriers on this floor it would be required to be immediately evacuated in the event of a fire.

b) On 5/27/10 at 3:01PM, the issues concerning the lack of a smoke barrier and the need to conduct an immediate evacuation of the 1st floor of the Main Building - Brackett Wing in the event of a fire was brought to the attention of the facility's Director of Engineering and the Director of Safety. They both said that rather than having this area conduct an immediate evacuation that they will install a smoke barrier of this floor.

42CFR 483.70(a)(1), NFPA 101-2000: 19.7.1.1, 19.7.2
.

Based on observations, the facility did not ensure that sprinkler systems were inspected, tested, or maintained in accordance with all of the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

a) On 5/24/10 at 11:42AM, a Holly tree was found growing directly in front of and blocking fire service access to a Main Building sprinkler system Fire Department connection (vicinity of the Maternity Unit). As per concurrent interview with the facility's Director of Engineering, the tree and any other bushes that obstruct access to the Fire Department connection will be removed immediately.

b) On 5/24/10 at 11:48AM, several bushes were found growing directly in front of and blocking fire service access to a Main Building combination sprinkler system/standpipe system Fire Department connection (vicinity of the Lab Unit). As per concurrent interview with the facility's Director of Engineering, the tree and any other bushes that obstruct access to the Fire Department connection will be removed immediately.

c) On the afternoon of 5/27/10, review of the sprinkler system maintenance, inspection, and testing records for the facility revealed that sprinkler system pressure gauges had not been calibrated or replaced within the last five (5) years, that sprinkler system alarm valves had not been inspected within the last five (5) years, and that sprinkler system check vales had not been inspected within the last five (5) years.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.5.1, 9.7.5, NFPA 25-1998: 2-1, 9-1, 9-7
.

Based on observations and interview, the facility did not ensure that all portable fire extinguishers were visually inspected at least once per month and maintained in good repair.

Findings:

On 5/26/10 at 8:35AM, a portable fire extinguisher in the Original Building - North Wing rooftop mechanical room was found to lack a monthly visual inspection record tag and the pressure gauge status indicator was on "recharge". As per concurrent interview with the facility's Director of Engineering, he would have this fire extinguisher immediately removed from service and replaced.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 4-3
.

Based on observations, the facility did not ensure that oxidizing gasses (e.g., nitrous oxide) were properly stored in accordance with NFPA 99-1999.

Findings:

On 5/24/10 at 2:30PM, three (3) unsecured nitrous oxide cylinders were noted in the 3rd Floor Oxygen Storage Room #B338 of the Main Building - Brackett Wing.

42CFR 483.70(a)(1), NFPA 99 - 1999: 8-3.1.11
.

Based on observations, the facility did not ensure that oxidizing gasses (e.g., oxygen) and flammable non-medical gasses (i.e., acetylene, propane) were properly stored in accordance with NFPA 99-1999.

Findings:

a) On 5/24/10 at 12:30PM improperly stored gases were noted in the exterior fenced in enclosure in the vicinity of the "O" exit stairwell. Reference is made to two (2) propane containers and one (1) acetylene cylinder that were stored twelve - twenty-four (12) - (24) inches from an oxygen cylinder. Oxidizing gases shall be separated from incompatible materials by a distance of twenty (20) feet in unsprinklered storage locations, five (5) feet in sprinklered locations or by placement in a one-half (½) hour rated cabinet.

- On 5/24/10 at 12:30PM unsecured freestanding compressed gas cylinders were noted in a different portion of the above mentioned storage area. Reference is made to an unsecured H size oxygen cylinder, fifteen (15) unsecured nitrous oxide cylinders and six (6) carbon dioxide cylinders.

42CFR 483.70(a)(1), NFPA 99 - 1999: 8-3.1.11
.

1. Based on observations and record (i.e., panelboard schedule) review the Main Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System.

For example:

- Emergency power panelboard LP-1WE (Location: Mech/Elect. Room 1st Floor Room #1408 Bracket Wing) served both sewage pumps (Equipment System) and a fire alarm control panel (Emergency System - Life Safety Branch).

- Emergency power panelboard ELS-1L (Location: Labor and Delivery) served both a sump pump (Equipment System) and a medical gas alarm (Emergency System - Life Safety Branch).

b) The wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

For example:

- Emergency power panelboard LP-1WE (Location: Mech/Elect. Room 1st Floor, Room #1408 Bracket Wing) served both a fire alarm control panel (Emergency System - Life Safety Branch) and a 3rd Floor Nursing Station (Emergency System - Critical Branch).

- Emergency power panelboard ELS-1L (Location: Labor and Delivery) served both a medical gas alarm (Emergency System - Life Safety Branch) and a nurse call panel (Emergency System - Critical Branch).

- Emergency power panelboard LP-1ME (Location: Electric closet #1017C, East Wing) served both a fire alarm panel (Emergency System - Life Safety Branch) and a receptacle for a security camera (Emergency System - Critical Branch).

- Emergency power panelboard GBE (Location: Same Day Surgery, 1st Floor Gulden Wing) served both exit access lighting (Emergency System - Life Safety Branch) and receptacles in patient rooms (Emergency System - Critical Branch).

- Emergency power panelboard LP-1PE (Location: Medical Records, 1st Floor East Wing) served both exit lights (Emergency System - Life Safety Branch) and a Board Room receptacle (Emergency System - Critical Branch).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


2. Based on observations, all ramps in the means of egress were not provided with handrails.

Findings:

a) On 5/24/10 at 12:06PM, it was noted that a ramp to grade at the exit discharge of an exit serving the Information Services (Main Building) area was not provided with handrails.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.6, 7.2.5


3. Based on observations the facility did not ensure that the arrangement of all means of egress in the Main Building was in accordance with NFPA 101-2000: 19.2.5.

Findings:

a) On the morning of 5/27/10, it was noted that a required means of exit access was through the Main Building 1st Floor cafeteria seating area. Corridors shall provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies.

b) Exit access on the 3rd Floor of the East Wing (i.e., ICU area) required suite to suite travel. Although suite to suite travel is permitted under certain conditions by NFPA 101-2006, neither CMS nor NYS has adopted the 2006 Edition of NFPA 101.

c) Exit access on the 1st floor "Fast Track" Emergency Department (ED) area required suite to suite travel through the adjacent ED suite. Although suite to suite travel is permitted under certain conditions by NFPA 101-2006, neither CMS nor NYS has adopted the 2006 Edition of NFPA 101.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5.9, 19.2.5.2, 19.2.5.8


4. Based on observations the facility did not ensure that doors in the means of egress that served rooms or spaces with an occupant load in excess of fifty (50) persons swung in the direction of exit travel.

Findings:

a) On the morning of 5/24/10, it was noted that the doors from the Main Building Board Room to the adjacent corridor did not swing in the direction of exit travel. The calculated occupant load of the room was in excess of fifty (50) persons (i.e., seventy-five (75) persons) and on 5/27/10 at 8:52AM, forty-six (46) non-fixed chairs were noted in the room.

10 NYCRR, 42CFR 483.70(a)(1), NFPA 101-2000: 19.1.2, 7.2.1.4.2

1. Based on observations and record (i.e., panelboard schedule) review the Original Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example, on 5/26/10 at 9:05AM, it was noted that Emergency Power Panel 3BE in the 3rd Floor of the Original Building - Center Wing served items from the Emergency System - Life Safety Branch (i.e., Circuit 32 Corridor lights), Emergency System - Critical Branch (i.e., Circuit #17 Receptacles at Nurses Station) and the Equipment System (i.e., Circuit #1 Air Handler).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


2. Based on observations and interview, the facility did not ensure that all sleeping rooms (i.e., Lodging and Rooming House occupancies) that would require a smoke detector were provided with one.

Findings:

a) On the morning of 5/26/10, eleven (11) out of twelve (12) on-call physician and physician assistant sleeping rooms located on 3rd Floor of the Original Building - Northwest Wing (e.g. Rooms #3314, #3315 and #3318) were found to lack required smoke detectors in the room.

b) On 5/26/10 at 9:15AM, interview with the facility's Director of Engineering revealed that he was not aware that the on-call sleeping rooms would require smoke detectors. He said he would inform his supervisor of this issue.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.2, 6.1.4, 26.3.3.5
.

Based on observations and interview, the facility did not ensure that temporary wiring and lighting fixtures were removed upon the completion of construction.

Findings:

On 5/26/10 at 8:53AM, temporary electrical wiring and lighting fixture were found above the suspended ceiling in the Original Building - Center Wing (in the vicinity of a 3rd Floor connecting corridor between this building an the Main Building - Tower Wing). As per concurrent interview with the facility's Director of Engineering, he will ensure that the temporary wiring is no longer energized and will attempt to remove it.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 305-3(d)