HospitalInspections.org

The facility did not assure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and as required by the referenced LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On 11/12/13 at 11:00 AM and times throughout the day, the surveyor along with the Director of Dietary & Support Services observed that the fire/smoke barriers above the suspended ceiling assembly for the corridor smoke doors throughout the facility had sleeves voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required and the walls also contained sleeves used for the passage of wires that were not sealed having at least a half hour fire resistance rating as required .

The facility did not assure that stairways and smoke proof towers used as exit are in accordance with section # 7.2 of the referenced, " Life Safety Code "

On 11/11/13 at 11:18 AM the surveyor while accompanied by the Maintenance Coordinator observed that the outside, exit stair and landing at the Enfield satellite location was not provided with stair treads and landing surfaces that were solid as required by section # 7.2.2.2.3.3 of the referenced, " Life Safety Code " ; i.e. treads & landing have the ability to trip users.

The facility did not ensure that exit access is arranged so that exits are readily accessible at all times as defined in section 7.1.

1. On 11/11/13 at 1:40 PM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Danielson satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. educational occupancy-no sprinkler, doors to classrooms wedges & held open;

2. On 11/12/13 at 9:00 AM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Old Saybrook satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. educational occupancy-no sprinkler, doors not provided with self-closing devices;

3. On 11/12/13 at 10:37 AM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Groton satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. 1st floor is educational occupancy-no sprinkler, doors not provided with self-closing devices and doors are not 1 ¾ inch (1 3/8)

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with section # ' s 4.6.12 & 7.9 of the referenced, " Life Safety Code "

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the battery backup emergency lights were inspected for 30 seconds each month and 90 minutes annually at Main Campus, Enfield, Vernon, Dayville, Danielson, Old Saybrook, Groton or Norwich satellite locations, as required by section # ' s 4.6.12 & 7.9 of the referenced, " Life Safety Code "

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70, " National Electrical Code" and NFPA 72, "National Fire Alarm Code " and that the system has an approved maintenance and testing program complying with applicable requirements of NFPA 70, " National Electrical Code" and NFPA 72, "National Fire Alarm Code" .

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the facility fire alarms at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being inspected, tested & maintained every 6 (six) months as required by NFPA 72, "National Fire Alarm Code " and by the facility ' s procedures & policies;

The facility did not ensure that all required smoke detectors, including those activating door hold open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications as require by the referenced LSC.

1. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the smoke detection system at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being inspected and tested on an annual basis as required in NFPA 72, "National Fire Alarm Code " and as part of the facility's preventive maintenance program; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any);

2. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that smoke detector sensitivity testing at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being performed according to and/or in compliance with NFPA 72, "National Fire Alarm Code" - 7-3.2.1 and as part of the facility's preventive maintenance program i.e. no electronic or written records of testing were available and no records smoke detector sensitivity testing were kept readily available or deficiencies discovered (if any).

3. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the Main Campus duct smoke detectors for RTU 3, RTU 1 and AHU 2 were tested according to and/or in compliance with NFPA 72, "National Fire Alarm Code" and as part of the facility's preventive maintenance program i.e. indicated on testing documentation could not locate on the last two (2) years of fire alarm inspections.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by section # 19.7.6 of the referenced LSC.

1. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the tamper and alarm signals were being tested at least quarterly on the sprinkler systems located at the Enfield, Vernon or Norwich satellite locations, as required by section # ' s 4.6.12 of the referenced, " Life Safety Code ";

2. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the automatic sprinkler systems at the Enfield, Vernon or Norwich satellite locations had preventative maintenance conducted on them that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, " Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" ; i.e. no record of obstruction investigation, (interior), strainer, filter & orifice inspection or (interior) check valve inspections;

3. On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation by Director of Dietary & Support Services to indicate that the deficiencies identified on the 05/15/13 automatic sprinkler system inspection and quoted for repair had been corrected i.e. nonfunctioning dry pipe valve accelerator, 30 corroded sprinkler heads, painted sprinkler heads, and concealer covers affixed with caulk.

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the fire dampers at the Norwich satellite location were inspected & maintained as required by NFPA 90A, " Standard for the Installation of Air Conditioning and Ventilation Systems "; i.e. no documentation provided of fire damper inspections or deficiencies discovered or repairs made (if any).

1. The facility did not ensure that all personnel were trained periodically in their duties and responsibilities in the emergency plans and procedures for the facility in accordance with NFPA 101 19.7.1.1, 19.7.1.3.

On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation from the Director of Dietary & Support Services that all employees had been in serviced on an annual basis as to their duties and responsibilities in the emergency plans and procedures for the facility in accordance with section # ' s 19.7.1.1 & 19.7.1.3 of the referenced, " Life Safety Code " and in accordance with the policies and procedures manual for the facility.


2. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation from the Director of Dietary & Support Services to indicate that all electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program i.e documentation reviewed lacked dates and locations for equipment tested.

The facility did not ensure that where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system as require by the referenced LSC.

On 11/12/13 & 11/13/13 at 9:30 AM and times throughout the day, the surveyor observed that the required procedure for instituting a fire watch was not followed i.e. the maintenance worker assigned to the fire watch was answering pages and calls for maintenance work and not touring the facility continually observing for fire conditions

The facility did not assure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 and as required by the referenced LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On 11/12/13 at 11:00 AM and times throughout the day, the surveyor along with the Director of Dietary & Support Services observed that the fire/smoke barriers above the suspended ceiling assembly for the corridor smoke doors throughout the facility had sleeves voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required and the walls also contained sleeves used for the passage of wires that were not sealed having at least a half hour fire resistance rating as required .

The facility did not assure that stairways and smoke proof towers used as exit are in accordance with section # 7.2 of the referenced, " Life Safety Code "

On 11/11/13 at 11:18 AM the surveyor while accompanied by the Maintenance Coordinator observed that the outside, exit stair and landing at the Enfield satellite location was not provided with stair treads and landing surfaces that were solid as required by section # 7.2.2.2.3.3 of the referenced, " Life Safety Code " ; i.e. treads & landing have the ability to trip users.

The facility did not ensure that exit access is arranged so that exits are readily accessible at all times as defined in section 7.1.

1. On 11/11/13 at 1:40 PM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Danielson satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. educational occupancy-no sprinkler, doors to classrooms wedges & held open;

2. On 11/12/13 at 9:00 AM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Old Saybrook satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. educational occupancy-no sprinkler, doors not provided with self-closing devices;

3. On 11/12/13 at 10:37 AM the surveyor while accompanied by the Maintenance Coordinator observed that the corridor was not separated from the rest of the story at the Groton satellite location, as required by section 15.3.6 of the referenced, " Life Safety Code " ; i.e. 1st floor is educational occupancy-no sprinkler, doors not provided with self-closing devices and doors are not 1 ¾ inch (1 3/8)

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with section # ' s 4.6.12 & 7.9 of the referenced, " Life Safety Code "

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the battery backup emergency lights were inspected for 30 seconds each month and 90 minutes annually at Main Campus, Enfield, Vernon, Dayville, Danielson, Old Saybrook, Groton or Norwich satellite locations, as required by section # ' s 4.6.12 & 7.9 of the referenced, " Life Safety Code "

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70, " National Electrical Code" and NFPA 72, "National Fire Alarm Code " and that the system has an approved maintenance and testing program complying with applicable requirements of NFPA 70, " National Electrical Code" and NFPA 72, "National Fire Alarm Code" .

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the facility fire alarms at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being inspected, tested & maintained every 6 (six) months as required by NFPA 72, "National Fire Alarm Code " and by the facility ' s procedures & policies;

The facility did not ensure that all required smoke detectors, including those activating door hold open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications as require by the referenced LSC.

1. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the smoke detection system at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being inspected and tested on an annual basis as required in NFPA 72, "National Fire Alarm Code " and as part of the facility's preventive maintenance program; i.e. no electronic or written records of testing were available and no records of maintenance were kept readily available or deficiencies discovered (if any);

2. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that smoke detector sensitivity testing at the Vernon, Old Saybrook, Groton or Norwich satellite locations are being performed according to and/or in compliance with NFPA 72, "National Fire Alarm Code" - 7-3.2.1 and as part of the facility's preventive maintenance program i.e. no electronic or written records of testing were available and no records smoke detector sensitivity testing were kept readily available or deficiencies discovered (if any).

3. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the Main Campus duct smoke detectors for RTU 3, RTU 1 and AHU 2 were tested according to and/or in compliance with NFPA 72, "National Fire Alarm Code" and as part of the facility's preventive maintenance program i.e. indicated on testing documentation could not locate on the last two (2) years of fire alarm inspections.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by section # 19.7.6 of the referenced LSC.

1. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the tamper and alarm signals were being tested at least quarterly on the sprinkler systems located at the Enfield, Vernon or Norwich satellite locations, as required by section # ' s 4.6.12 of the referenced, " Life Safety Code ";

2. On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the automatic sprinkler systems at the Enfield, Vernon or Norwich satellite locations had preventative maintenance conducted on them that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, " Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" ; i.e. no record of obstruction investigation, (interior), strainer, filter & orifice inspection or (interior) check valve inspections;

3. On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation by Director of Dietary & Support Services to indicate that the deficiencies identified on the 05/15/13 automatic sprinkler system inspection and quoted for repair had been corrected i.e. nonfunctioning dry pipe valve accelerator, 30 corroded sprinkler heads, painted sprinkler heads, and concealer covers affixed with caulk.

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 11/13/13 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Coordinator to indicate that the fire dampers at the Norwich satellite location were inspected & maintained as required by NFPA 90A, " Standard for the Installation of Air Conditioning and Ventilation Systems "; i.e. no documentation provided of fire damper inspections or deficiencies discovered or repairs made (if any).

1. The facility did not ensure that all personnel were trained periodically in their duties and responsibilities in the emergency plans and procedures for the facility in accordance with NFPA 101 19.7.1.1, 19.7.1.3.

On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation from the Director of Dietary & Support Services that all employees had been in serviced on an annual basis as to their duties and responsibilities in the emergency plans and procedures for the facility in accordance with section # ' s 19.7.1.1 & 19.7.1.3 of the referenced, " Life Safety Code " and in accordance with the policies and procedures manual for the facility.


2. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 11/13/13 at 1:30 PM, the surveyor was not provided with documentation from the Director of Dietary & Support Services to indicate that all electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program i.e documentation reviewed lacked dates and locations for equipment tested.

The facility did not ensure that where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system as require by the referenced LSC.

On 11/12/13 & 11/13/13 at 9:30 AM and times throughout the day, the surveyor observed that the required procedure for instituting a fire watch was not followed i.e. the maintenance worker assigned to the fire watch was answering pages and calls for maintenance work and not touring the facility continually observing for fire conditions