HospitalInspections.org

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not adequately protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

The findings are:

During the survey from 04/23/14 to 04/25/14 between 11:00 AM to 4:00 PM, observations were made in areas where the structural beam was visible from the floor level or an above ceiling inspection was done. During the observation it was revealed that the I-beams and steel beams / steel web truss assemblies / steel supporting the weight of the deck above in many places were not completely protected with a fire resistive material.

Few examples of some unprotected I-beams including, but not limited to, are:
i. Structural beam in the electrical closet of 8th floor-LDRP unit-Main Building.
ii. Various areas on the structural beam in the electrical rooms including but not limited to electrical room of 2nd floor-Med/Surg Unit-Main Building.
iii. Various areas on the structural beam in the Elevator room including on the roof.

Findings were verified with Senior Associate Director Facilities and Engineering Staff accompanying the surveyor during the survey.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
.

Based on observation, the facility did not ensure that hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1. Furthermore, the facility did not ensure that hazardous areas are safeguarded by one hour construction or automatic fire extinguishing system.

Findings include:

1. On 04/24/14 at 3:00 PM, during the tour Main Clean Linen room located on the first floor Main building, it was noted that the door of the room held open by a door stopper.

2. During tour of the 3rd floor- Psych unit-Hammet Building on 04/25/14 at 11:45 AM, it was noted that the activity room has two supplies closet stocked with paper and other combustible supplies. These two closets are located adjacent to each other. The square footage of each closet was told to the surveyor to be 32 SF. Therefore approximately a total of 64 SF of closet in the area adjacent housing combustible items did not have any sprinklers for fire protection nor a one hour rating could be verified at the time of survey. As per NFPA 101 2000 Combustible Storage rooms/spaces over 50 Sq feet should be protected as hazardous area.


Above findings were verified with the Senior Associate Director Facilities at the time of observation.

Based on observation, the facility failed to maintain the width of the exit access to be 4 feet and free of obstruction, as required by NFPA101 2000 Edition.

Findings Include:

During the tour of the Primary Care Clinic Suite on 04/25/14 at approximately 11:00 AM, it was noted that the width of the egress path in the Primary Care clinic 2 was reduced to three and half (31/2) feet by the storage of computer station, weighing scale and a clean supply cart.

Similar observation was also made in the Primary Care clinic 3.

Based on observation and staff interview, the facility failed to ensure that the facility is equipped with all required fire alarm devices to provide effective warning to all occupants, as required by NFPA72.

Findings include:

During the tour of the Audiology clinic on 04/25/14 at approximately 3:30 PM on the 4th Floor of the hospital, it was noted that the audiology booth and the clinic did not have strobes. Strobes are required in this area to alert patients,who are hard of hearing in an event when the fire alarm system is activated. This finding was again confirmed with the Senior Associate Executive Director.

Based on record review and staff interview, the facility did not ensure that all the components of the fire alarm system were tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code.

The findings include:

On 04/28/14 at 2:30 PM, during different document review of the fire alarm and the test of its different components, it was noted that the report did not include any information on the testing of the batteries of the fire alarm system as per NFPA 72 (1999) 7-1 and 7-3.2.

On 04/29/14 at 11:30 AM, Senior Associate Director Facilities ( SADF) was asked to provide documentation for semi-annual 30 minute discharge test of fire alarm batteries if they are lead-acid type along with the Load Voltage Test. The stated that the facility has Nickel-Cadmium type batteries which require annual 30 minutes discharge test. Furthermore he stated that the facility changes the battery every year thus the testing is not required since the battery is new.

The Supervisor Electrician confirmed at 1:30 PM that the battery is not nickel and is lead-acid type. No information and the verification for the semi-annual discharge tests and verification of load voltage test results were provided.

All above findings were verified with Senior Associate Director Facilities and Supervisor Electrician at the time of observation.

Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1 Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

1. On 04/28/14 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Senior Associate Director Facilities that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, cross main and, branch line.

2. On 04/28/14 at 12:30 PM for the review of five year 'Standpipe Hydrostatic test and Flow Test' a certification was provided by the facility dated 06//13. This certification or any other report did not have the information that the test was done for 2 hrs and not less than 200 PSI.
Senior Associate Director Facilities stated that this test is conducted in presence of FDNY and witnessed by them therefore it is the only proof of test the facility has.

It is to be noted that the document clearly states that the 'test' is in accordance with the Department's / FDNY regulation and does not state that the test is in lieu / alternative / equivalent / acceptable or in compliance as per NFPA 25.

As per NFPA 25 1999 section 3-3.2.1
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

All above findings were verified with Senior Associate Director Facilities and the engineering personnel present at the time of review.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility from 04/23/14 to 04/25/14 between 10:30 AM to 3:45 PM, it was noted that in the various floors of the Main and Hammet building of the facility, the fire extinguishers were installed on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

Examples including but not limited to are:

i. All the extinguishers were above 5 feet in the OR suite 7th floor.
ii. Extinguisher were noted to be above 5 feet on the 2nd floor of the main building in the corridor near Central Sterilization Processing room.
iii. Extinguisher were noted to be above 5 feet on the 4th floor of the Hammet building near the janitor's closet #454.


2. During survey of the facility from 04/23/14 to 04/25/14 , it was noted that some of the fire extinguishers were installed or blocked by chairs, tables or equipment thus making the portable extinguishers in such a way that they are not readily accessible at the time of emergency.

Examples including but not limited to:

i. A fire extinguisher cabinet was noted installed behind the double smoke door of Emergency Department Entrance from the corridor connecting it to other others of the building. The doors are kept open and the cabinet was noted hidden behind the leaf of the door.

ii. A fire extinguisher was noted blocked in the waiting room for vision and hearing test of the Pediatric Clinic-1st floor.-Tower.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

All findings for extinguishers issue were observed and verified with Senior Associate Director Facilities.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. (a) On 04/28/14 at 2:00 PM, during review of the latest fire/smoke damper assessment of the facility, it was noted that many dampers had deficiencies in the different buildings of the campus. A follow up report or work order was indicating that all the issues indicated in the report were resolved was not available. As per Chief Engineer this a work in process and the work of damper corrective issue is under way. However, no time line or comprehensive plan was provided regarding when all issues noted in the last report will be resolved.


(b) In reviewing the damper report dated of 2008 to see if there were any damper issues in the facility that were existing for a long time, it was noted that in the Main building there were some dampers that had issues since 2008 and no corrective action took place for them.

Examples including but not limited to are:
i. Damper # FD-1-029 (1-21 written in older report for Room #105) in Main Building failed in 2008. As per the Chief Engineer the facility has currently the work not reached this damper so the issue may be fixed and the latest damper number the facility is working on this time on the floor is FD-1-021.

ii. Two Damper with #s FD-9-015( 9-26 and 9-25 written in older report) in Main Building failed in 2008. In reviewing the latest corrective report it was noted that one of the damper which was obstructed was corrected while for the other it is still stated in the corrective action report that no access to the damper was available due to telephone wires blocking it and thus it was not tested.
2. During the inspection of the fire and smoke barriers in the facility from 04/24/14 to 04/25/14 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer's installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.

On of the examples of fire retardant material around the ducts was the duct passing the fire/smoke barrier in the Information Technology room #220 on the 2nd floor-Med Surg unit -Tower had fire retardant around it. Furthermore, a gap between the retaining angle and the rated wall was also noted.

Thus facility did not ensure that the ducts with fire dampers do not have their retaining angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Senior Associate Director Facilities.

Based on observations and document review, the facility did not ensure that the bulk oxygen storage tanks were stored in a safe manner, protected from the elements, and that the storage area was clear of debris. Furthermore facility did not ensure location of medical gas storage more than 3,000 cu FT had the required ventilation.

Findings are:


1. During the tour of the Main Oxygen Bulk tank on 04/24/14 at 2:15 PM , it was noted that an accumulation of decayed foliage and debris, such as dead decayed leaves were lying around the Oxygen bulk tank and underneath the storage area of liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily.

Findings were verified with Senior Associate Director Facilities.

NFPA 99 4-3.1.2.2

2. During document review for the Medical Gas Manifold on 04/27/14 at 2:45 PM, it was noted that the report dated December 2012 stated that the "Following areas do not meet ventilation requirement. Location Gnd floor main room N2O. Install dedicated mechanical ventilation."

The Director of Engineer stated that he is in a process of buying a fan for this area and thus the issue has not been resolved.

All above findings were verified with Senior Associate Director Facilities and Director of Engineering.

Based on observation and staff interview it was determined that the facility did not maintain the line pressure of the piped in medical gas system as per NFPA 99 in different patient areas.

Findings include:

During the survey of the facility from 04/23/14 to 04/25/14 between 10:30 AM to 3:45 PM, it was noted that the oxygen pressure reading on the medical gas alarm panel on the patient floors were between 48 PSI to 49 PSI. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard line pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Examples including but not limited to are:
i. LDRP- 8th floor Main Building the O2 reading on the panel was between 48-49 PSI.
ii. Med/Surg unit -8th floor Tower the O2 reading on the panel was 48 PSI.


Findings were verified with the Senior Associate Director Facilities.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 04/24/14 to 04/25/14 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas/rooms were also inspected for integrity.

It was noted that the barriers were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, include, but were not limited to:

a. During the tour of the LDRP unit 8th floor Main Building, it was noted that in the Electrical Closet #8N18 the fire/smoke barrier rated wall had unsealed penetrations made by ducts, conduits and pipes. In room #8N1A there were penetrations made by green cable wires.

b. During the tour of the Med/Surg unit 2nd floor Tower Building, it was noted that there was breach in the integrity of the rated wall in room #220 made by conduit.

c. During the tour of the Psych unit 3rd floor Hammet Building, it was noted that there was breach in the integrity of the rated wall in electrical room #334.


All above findings were verified with Senior Associate Director Facilities.

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 ensuring the transfer to emergency power in 10 seconds. Furthermore facility did not have a maintenance program for the transfer switches.

Findings include.

1. 04/28/14 at 12:30 PM, during documentation review of the emergency generator monthly load test logs, it was noted that there was no transfer time record for the transfer switches on emergency generators. The facility in its form of 'Generator Test/Automatic Transfer Switch Preventive Maintenance' documents 'OK' under the column "Seconds to transfer from normal to emergency power". This was observed in all the test records for the year 2013 and the months of January and February of 2014. In the month of March 2014 facility indicated in the comments section that 'Generator #1-Mitsubishi-1200 KW load' that engine started in 8.5 seconds". Such information was not provided for generator #2 in any month to ensure it will transfer within 10 seconds too when needed.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Therefore based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with the Senior Associate Director Facilities, Director of Engineering, Chief Enginner and Supervisor Electrician.


2. Facility was requested on 04/28/14 to provide evidence for the maintenance program of the transfer switches as required by NFPA 110 99 section 6-3.5 :Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.

Facility could not provide documented evidence that there is an established maintenance program that is followed by the facility which includes checking for all parameters required by the code.

On 04/29/14 at 12:15 PM, Senior Associate Director of Facilities provided a report of 'ATS scheduled Maintenance Data sheet' which was dated 08/2012. No other current document was provided for such ATS/Transfer switches maintenance.

Findings were verified with the Senior Associate Director Facilities and Supervisor Electrician.

A. Based on observation, facility did not ensure that the stairwell exit signs have all required information as per NFPA 101 7.2.2..5.4 and that they are installed in such a manner that they are readily visible in the open and closed position of the doors.

Findings include:

During the survey of the facility from 04/23/14 to 04/25/14 between 11:00 AM to 3:45 PM, it was noted that the stairwell signs in the staircase were not installed in a manner that vital egress information is seen by the occupants of a building and by fire fighters in case of emergency when the door is in the open or closed position.


Note: NFPA 101 2000 Section 7.2.2.5.4* Stair Identification Signs states that:
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.


All findings were verified Senior Associate Director Facilities.

B. Based on document review and staff interview, facility did not ensure that the electrical safety test was conducted on the patient care instruments as per frequency defined by NFPA 99.

Findings include:

On 04/29/14 at 12:00 PM facility was requested to provide information for the critical and non-critical patient care equipments. As per the Director of Bio-med the electrical checks are done as a part and frequency of preventive maintenance prescribed for the equipment. It was observed during document review that the Servo-I ventilators had their preventive maintenance once a year and therefore got their electrical safety check annually. A ventilator is considered a critical or life support equipment and therefore as per NFPA 99 the frequency of electrical safety check should be bi-annually. There was no documented justification available/provided based on previous results that may allow the ventilator to have only an annual electrical safety check.

Note: NFPA 99 Section 7-6.2.1.2 Testing Intervals.

a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.

b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General Care Areas - 12 Months
Critical Care Areas - 6 Months
Wet Locations - 6 Months

Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations.

Exception No. 2: Facility-owned household or other appliances that are used in the patient care vicinity, but that are not intended to contact the patient, shall be tested at intervals deemed appropriate by the facility. Some equipment in this category requires only an infrequent visual inspection. The facility shall be permitted to structure a testing protocol and frequency for some equipment that might be more limited than that prescribed in 7-5.1.3.

Exception No. 3: The tests specified in 7-5.1.3.6, Lead Leakage Current Tests and Limits, Portable Equipment, shall be required only for incoming inspections and following repairs and modifications that might have compromised the patient lead leakage current.

Exception No. 4: * After the installation of fixed equipment, it shall be tested periodically in accordance with 3-3.3.2.3 and meet the following criteria:

(a) 500 mV for General Care Areas
(b) 40 mV for Critical Care Areas

Findings were verified with the Director of Bio-Med and the Bio-Med personnel.

c. Based on staff interview and document review all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 04/28/14 at 3:00 PM, the Senior Associate Director Facilities (SADF) was requested to provide evidence that electrical receptacles in the patient care areas were tested.

On 04/29/14 at 11:45 AM, (SADF) provided some electrical testing from 2009 for Main Building and 2000 records for Hammet building. No records were provided for Tower building.

Furthermore, those reports indicated some repairs to be done and no follow-up was provided for those repairs.

The facility also did not have any policy and procedure or statistics in place regarding the frequency the test be conducted if not annually. Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

Findings were verified with Senior Associate Director Facilities.

D. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Tower Building.

Findings include:

On 04/23/14 at 12:15 PM during the tour of the Nursery and NICU on 8th floor -Tower Building, it was noted that the supplies closet did not have any sprinkler head. The tower building is a fully sprinklered building with date of certification of 2006.

It is to be noted that NFPA 13, Section 5-1.1, states that a building with sprinklers installed throughout is considered fully sprinklered.

Furthermore section 5-13.1.1* states that:
All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers.

Closets are part of the building structure, which have the walls, ceiling, and floor generally made of the same construction materials as the building. Closets are required to be sprinklered in a sprinklered building.


Findings were observed and verified with Senior Associate Director Facilities.

Based on document review and staff interview, the Main Building of the facility does not the three branches of generator divided into Life Safety, Critical and Equipment branch. The facility performs general anesthesia in its Main Building and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). Furthermore the wiring of the electrical system at the panels on patient care floors in the Tower building (build in 2003) are not in compliance with the code, NFPA 99 3-4.

Findings include:

1. In an interview with Supervisor Electrician and Senior Associate Director Facilities on 04/28/14 at 2:00 PM, it was indicated that the wiring configuration in the Main Building of the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation and wiring of the generator branches into a life safety, critical, and equipment system was not done for the panels in Main building area and patient floors. Thus the three branches has mixed wiring for life safety, and critical in whatever panel it is present in the Main building facility and are not segregated into three branches.
The Senior Associate Director Facilities stated that this is an old building from 1950's which did not require three branches at the time of construction, however as per the Certificate of Need records with the Department of Health, the facility has had major work done in the building in terms of renovation, upgrade of electrical system and addition of wings in the last few years and hence compliance with NFPA 99 is required.

2. During tour of the Tower building and document review of the panel and switches between 04/24/14 to 04/25/14 between 11:00 AM to 3:30 PM it was observed that the some of the wiring for items required to be served by the Emergency System - Critical were not independent from wiring for items required to be served by the Emergency System - Life Safety Branch.

Examples include:
i. The Life Safety Panel on 8th floor - LSLP8 was serving circuits in room#s such as 806A, 800B, 816A and similar many other rooms.
ii. The Life Safety Panel on 1st floor - LSLP1 was serving circuits in room#s such as 184, 100, 166, 104 and similar many other rooms. Furthermore it was also noted to have refrigerator hooked on it.
iii. The Panel LSRP1 on 1st floor which was described by the staff to be a life safety panel did not have any directory and therefore it could not be determined what items were wired to this panel.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.


All above findings were verified with Senior Associate Director Facilities.



1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Based on observation, facility did not ensure that power strips are not used as a permanent source of power from an electrical receptacle.
Findings include
On 04/25/14 at 12:55 PM, during the tour of the Medical Intensive Care Unit-7th floor Tower building, it was observed that a power strip was installed in the Clean Utility Room. Two to three items were plugged in on the strip.
As per Senior Associate Director Facilities, the hospital realizes that there should be no use of power strips in the facility. However he did not know how and when this particular strip was installed in a way that it was serving as a solution for permanent electrical receptacle.
NFPA 70 states that Power strips may not be used as a substitute for adequate electrical outlets in a facility.

Findings were verified with Senior Associate Director Facilities and Nurse Manager of the unit.

Based on observations, the facility did not ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed directly over or adjacent to an ignition source in many areas across the different buildings of the facility.

Life Safety Code section 19.3.2.7 does not permit the installation of Alcohol Based Hand Rub (ABHR) dispensers directly over or adjacent to an ignition source.

Findings include:

During the survey of the Pediatric Clinic - 1st floor Tower on 04/25/14 at 3;00 PM, it was noted that in some rooms including, but not limited to room #105B, the Alcohol Based Hand Rub (ABHR) dispensers were installed directly above an ignition source (i.e., electric light switches)


Findings were verified with the Senior Associate Director Facilities and the Director of Nursing.

Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not adequately protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type I (332).

The findings are:

During the survey from 04/23/14 to 04/25/14 between 11:00 AM to 4:00 PM, observations were made in areas where the structural beam was visible from the floor level or an above ceiling inspection was done. During the observation it was revealed that the I-beams and steel beams / steel web truss assemblies / steel supporting the weight of the deck above in many places were not completely protected with a fire resistive material.

Few examples of some unprotected I-beams including, but not limited to, are:
i. Structural beam in the electrical closet of 8th floor-LDRP unit-Main Building.
ii. Various areas on the structural beam in the electrical rooms including but not limited to electrical room of 2nd floor-Med/Surg Unit-Main Building.
iii. Various areas on the structural beam in the Elevator room including on the roof.

Findings were verified with Senior Associate Director Facilities and Engineering Staff accompanying the surveyor during the survey.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
.

Based on observation, the facility did not ensure that hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1. Furthermore, the facility did not ensure that hazardous areas are safeguarded by one hour construction or automatic fire extinguishing system.

Findings include:

1. On 04/24/14 at 3:00 PM, during the tour Main Clean Linen room located on the first floor Main building, it was noted that the door of the room held open by a door stopper.

2. During tour of the 3rd floor- Psych unit-Hammet Building on 04/25/14 at 11:45 AM, it was noted that the activity room has two supplies closet stocked with paper and other combustible supplies. These two closets are located adjacent to each other. The square footage of each closet was told to the surveyor to be 32 SF. Therefore approximately a total of 64 SF of closet in the area adjacent housing combustible items did not have any sprinklers for fire protection nor a one hour rating could be verified at the time of survey. As per NFPA 101 2000 Combustible Storage rooms/spaces over 50 Sq feet should be protected as hazardous area.


Above findings were verified with the Senior Associate Director Facilities at the time of observation.

Based on observation, the facility failed to maintain the width of the exit access to be 4 feet and free of obstruction, as required by NFPA101 2000 Edition.

Findings Include:

During the tour of the Primary Care Clinic Suite on 04/25/14 at approximately 11:00 AM, it was noted that the width of the egress path in the Primary Care clinic 2 was reduced to three and half (31/2) feet by the storage of computer station, weighing scale and a clean supply cart.

Similar observation was also made in the Primary Care clinic 3.

Based on observation and staff interview, the facility failed to ensure that the facility is equipped with all required fire alarm devices to provide effective warning to all occupants, as required by NFPA72.

Findings include:

During the tour of the Audiology clinic on 04/25/14 at approximately 3:30 PM on the 4th Floor of the hospital, it was noted that the audiology booth and the clinic did not have strobes. Strobes are required in this area to alert patients,who are hard of hearing in an event when the fire alarm system is activated. This finding was again confirmed with the Senior Associate Executive Director.

Based on record review and staff interview, the facility did not ensure that all the components of the fire alarm system were tested in accordance with the requirements of NFPA 101 and NFPA 72, National Fire Alarm Code.

The findings include:

On 04/28/14 at 2:30 PM, during different document review of the fire alarm and the test of its different components, it was noted that the report did not include any information on the testing of the batteries of the fire alarm system as per NFPA 72 (1999) 7-1 and 7-3.2.

On 04/29/14 at 11:30 AM, Senior Associate Director Facilities ( SADF) was asked to provide documentation for semi-annual 30 minute discharge test of fire alarm batteries if they are lead-acid type along with the Load Voltage Test. The stated that the facility has Nickel-Cadmium type batteries which require annual 30 minutes discharge test. Furthermore he stated that the facility changes the battery every year thus the testing is not required since the battery is new.

The Supervisor Electrician confirmed at 1:30 PM that the battery is not nickel and is lead-acid type. No information and the verification for the semi-annual discharge tests and verification of load voltage test results were provided.

All above findings were verified with Senior Associate Director Facilities and Supervisor Electrician at the time of observation.

Based on document review and staff interview, it was determined that the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1 Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.

Findings include:

1. On 04/28/14 at 12:00 PM, during documentation review for the sprinkler test, it was noted and verified by Senior Associate Director Facilities that there are no documentation or report available to show that five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim and check valves were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

Note: As per NFPA, there are two activities that are related to obstructions in Chapter 13 that require attention. The first is an investigation that is actually more of an "inspection" as described in Section 13.2.1 that must be conducted every five years. While the sprinkler system is shut down for the purpose of internal valve inspections (See Table 12.1), the flushing connection at the end of one cross main and a single sprinkler at the end of one branch line must be removed and the inside of the piping is then "inspected" for the presence of organic and inorganic material. In Section 13.2.2 a more comprehensive obstruction "investigation" must be conducted when any of the 14 conditions listed in that section are present. This more comprehensive obstruction "investigation" is conducted by internally examining the following four points in a system: system valve, riser, cross main and, branch line.

2. On 04/28/14 at 12:30 PM for the review of five year 'Standpipe Hydrostatic test and Flow Test' a certification was provided by the facility dated 06//13. This certification or any other report did not have the information that the test was done for 2 hrs and not less than 200 PSI.
Senior Associate Director Facilities stated that this test is conducted in presence of FDNY and witnessed by them therefore it is the only proof of test the facility has.

It is to be noted that the document clearly states that the 'test' is in accordance with the Department's / FDNY regulation and does not state that the test is in lieu / alternative / equivalent / acceptable or in compliance as per NFPA 25.

As per NFPA 25 1999 section 3-3.2.1
'Hydrostatic tests at not less than 200-psi (13.8-bar) pressure for 2 hours, or at 50 psi (3.4 bar) in excess of the maximum pressure, where maximum pressure is in excess of 150 psi (10.3 bar), shall be conducted every 5 years on dry standpipe systems and dry portions of wet standpipe systems'.

All above findings were verified with Senior Associate Director Facilities and the engineering personnel present at the time of review.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10). Additionally, the facility did not ensure that the fire extinguishers are stored in such a manner that they are easily accessible.

Findings include:

1. During survey of facility from 04/23/14 to 04/25/14 between 10:30 AM to 3:45 PM, it was noted that in the various floors of the Main and Hammet building of the facility, the fire extinguishers were installed on the wall or in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

Examples including but not limited to are:

i. All the extinguishers were above 5 feet in the OR suite 7th floor.
ii. Extinguisher were noted to be above 5 feet on the 2nd floor of the main building in the corridor near Central Sterilization Processing room.
iii. Extinguisher were noted to be above 5 feet on the 4th floor of the Hammet building near the janitor's closet #454.


2. During survey of the facility from 04/23/14 to 04/25/14 , it was noted that some of the fire extinguishers were installed or blocked by chairs, tables or equipment thus making the portable extinguishers in such a way that they are not readily accessible at the time of emergency.

Examples including but not limited to:

i. A fire extinguisher cabinet was noted installed behind the double smoke door of Emergency Department Entrance from the corridor connecting it to other others of the building. The doors are kept open and the cabinet was noted hidden behind the leaf of the door.

ii. A fire extinguisher was noted blocked in the waiting room for vision and hearing test of the Pediatric Clinic-1st floor.-Tower.

Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

All findings for extinguishers issue were observed and verified with Senior Associate Director Facilities.

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. (a) On 04/28/14 at 2:00 PM, during review of the latest fire/smoke damper assessment of the facility, it was noted that many dampers had deficiencies in the different buildings of the campus. A follow up report or work order was indicating that all the issues indicated in the report were resolved was not available. As per Chief Engineer this a work in process and the work of damper corrective issue is under way. However, no time line or comprehensive plan was provided regarding when all issues noted in the last report will be resolved.


(b) In reviewing the damper report dated of 2008 to see if there were any damper issues in the facility that were existing for a long time, it was noted that in the Main building there were some dampers that had issues since 2008 and no corrective action took place for them.

Examples including but not limited to are:
i. Damper # FD-1-029 (1-21 written in older report for Room #105) in Main Building failed in 2008. As per the Chief Engineer the facility has currently the work not reached this damper so the issue may be fixed and the latest damper number the facility is working on this time on the floor is FD-1-021.

ii. Two Damper with #s FD-9-015( 9-26 and 9-25 written in older report) in Main Building failed in 2008. In reviewing the latest corrective report it was noted that one of the damper which was obstructed was corrected while for the other it is still stated in the corrective action report that no access to the damper was available due to telephone wires blocking it and thus it was not tested.
2. During the inspection of the fire and smoke barriers in the facility from 04/24/14 to 04/25/14 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer's installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.

On of the examples of fire retardant material around the ducts was the duct passing the fire/smoke barrier in the Information Technology room #220 on the 2nd floor-Med Surg unit -Tower had fire retardant around it. Furthermore, a gap between the retaining angle and the rated wall was also noted.

Thus facility did not ensure that the ducts with fire dampers do not have their retaining angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Senior Associate Director Facilities.

Based on observations and document review, the facility did not ensure that the bulk oxygen storage tanks were stored in a safe manner, protected from the elements, and that the storage area was clear of debris. Furthermore facility did not ensure location of medical gas storage more than 3,000 cu FT had the required ventilation.

Findings are:


1. During the tour of the Main Oxygen Bulk tank on 04/24/14 at 2:15 PM , it was noted that an accumulation of decayed foliage and debris, such as dead decayed leaves were lying around the Oxygen bulk tank and underneath the storage area of liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily.

Findings were verified with Senior Associate Director Facilities.

NFPA 99 4-3.1.2.2

2. During document review for the Medical Gas Manifold on 04/27/14 at 2:45 PM, it was noted that the report dated December 2012 stated that the "Following areas do not meet ventilation requirement. Location Gnd floor main room N2O. Install dedicated mechanical ventilation."

The Director of Engineer stated that he is in a process of buying a fan for this area and thus the issue has not been resolved.

All above findings were verified with Senior Associate Director Facilities and Director of Engineering.

Based on observation and staff interview it was determined that the facility did not maintain the line pressure of the piped in medical gas system as per NFPA 99 in different patient areas.

Findings include:

During the survey of the facility from 04/23/14 to 04/25/14 between 10:30 AM to 3:45 PM, it was noted that the oxygen pressure reading on the medical gas alarm panel on the patient floors were between 48 PSI to 49 PSI. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard line pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Examples including but not limited to are:
i. LDRP- 8th floor Main Building the O2 reading on the panel was between 48-49 PSI.
ii. Med/Surg unit -8th floor Tower the O2 reading on the panel was 48 PSI.


Findings were verified with the Senior Associate Director Facilities.

Based on observation in the different areas of the facility, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

During the tour of the facility from 04/24/14 to 04/25/14 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas/rooms were also inspected for integrity.

It was noted that the barriers were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes. These penetrations were not completely sealed all around with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

Examples, include, but were not limited to:

a. During the tour of the LDRP unit 8th floor Main Building, it was noted that in the Electrical Closet #8N18 the fire/smoke barrier rated wall had unsealed penetrations made by ducts, conduits and pipes. In room #8N1A there were penetrations made by green cable wires.

b. During the tour of the Med/Surg unit 2nd floor Tower Building, it was noted that there was breach in the integrity of the rated wall in room #220 made by conduit.

c. During the tour of the Psych unit 3rd floor Hammet Building, it was noted that there was breach in the integrity of the rated wall in electrical room #334.


All above findings were verified with Senior Associate Director Facilities.

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

Based on staff interview and document review, the facility failed to maintain the emergency generators in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110 ensuring the transfer to emergency power in 10 seconds. Furthermore facility did not have a maintenance program for the transfer switches.

Findings include.

1. 04/28/14 at 12:30 PM, during documentation review of the emergency generator monthly load test logs, it was noted that there was no transfer time record for the transfer switches on emergency generators. The facility in its form of 'Generator Test/Automatic Transfer Switch Preventive Maintenance' documents 'OK' under the column "Seconds to transfer from normal to emergency power". This was observed in all the test records for the year 2013 and the months of January and February of 2014. In the month of March 2014 facility indicated in the comments section that 'Generator #1-Mitsubishi-1200 KW load' that engine started in 8.5 seconds". Such information was not provided for generator #2 in any month to ensure it will transfer within 10 seconds too when needed.

To meet state and Federal licensure requirements, healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:
a. Time delay on start: 1 second minimum.*
Exception: Gas turbine cycle: 0.5 second minimum.
*Note: NFPA 101(00), Sec. 7.9.1.2 requires that emergency loads be picked up within 10 seconds.
Therefore based on the review of facility's logs it could not be revealed if the generators meet the above guidelines since there was no transfer time or load pick up time indicated in the logs.
Note: It is important to verify that the emergency generator is capable of transferring the load as per the following requirements of every monthly load test:

NFPA 99 1999 - 3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source.
The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 99 1999- 3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1].

Findings were verified with the Senior Associate Director Facilities, Director of Engineering, Chief Enginner and Supervisor Electrician.


2. Facility was requested on 04/28/14 to provide evidence for the maintenance program of the transfer switches as required by NFPA 110 99 section 6-3.5 :Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.

Facility could not provide documented evidence that there is an established maintenance program that is followed by the facility which includes checking for all parameters required by the code.

On 04/29/14 at 12:15 PM, Senior Associate Director of Facilities provided a report of 'ATS scheduled Maintenance Data sheet' which was dated 08/2012. No other current document was provided for such ATS/Transfer switches maintenance.

Findings were verified with the Senior Associate Director Facilities and Supervisor Electrician.

A. Based on observation, facility did not ensure that the stairwell exit signs have all required information as per NFPA 101 7.2.2..5.4 and that they are installed in such a manner that they are readily visible in the open and closed position of the doors.

Findings include:

During the survey of the facility from 04/23/14 to 04/25/14 between 11:00 AM to 3:45 PM, it was noted that the stairwell signs in the staircase were not installed in a manner that vital egress information is seen by the occupants of a building and by fire fighters in case of emergency when the door is in the open or closed position.


Note: NFPA 101 2000 Section 7.2.2.5.4* Stair Identification Signs states that:
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.


All findings were verified Senior Associate Director Facilities.

B. Based on document review and staff interview, facility did not ensure that the electrical safety test was conducted on the patient care instruments as per frequency defined by NFPA 99.

Findings include:

On 04/29/14 at 12:00 PM facility was requested to provide information for the critical and non-critical patient care equipments. As per the Director of Bio-med the electrical checks are done as a part and frequency of preventive maintenance prescribed for the equipment. It was observed during document review that the Servo-I ventilators had their preventive maintenance once a year and therefore got their electrical safety check annually. A ventilator is considered a critical or life support equipment and therefore as per NFPA 99 the frequency of electrical safety check should be bi-annually. There was no documented justification available/provided based on previous results that may allow the ventilator to have only an annual electrical safety check.

Note: NFPA 99 Section 7-6.2.1.2 Testing Intervals.

a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.

b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General Care Areas - 12 Months
Critical Care Areas - 6 Months
Wet Locations - 6 Months

Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations.

Exception No. 2: Facility-owned household or other appliances that are used in the patient care vicinity, but that are not intended to contact the patient, shall be tested at intervals deemed appropriate by the facility. Some equipment in this category requires only an infrequent visual inspection. The facility shall be permitted to structure a testing protocol and frequency for some equipment that might be more limited than that prescribed in 7-5.1.3.

Exception No. 3: The tests specified in 7-5.1.3.6, Lead Leakage Current Tests and Limits, Portable Equipment, shall be required only for incoming inspections and following repairs and modifications that might have compromised the patient lead leakage current.

Exception No. 4: * After the installation of fixed equipment, it shall be tested periodically in accordance with 3-3.3.2.3 and meet the following criteria:

(a) 500 mV for General Care Areas
(b) 40 mV for Critical Care Areas

Findings were verified with the Director of Bio-Med and the Bio-Med personnel.

c. Based on staff interview and document review all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 04/28/14 at 3:00 PM, the Senior Associate Director Facilities (SADF) was requested to provide evidence that electrical receptacles in the patient care areas were tested.

On 04/29/14 at 11:45 AM, (SADF) provided some electrical testing from 2009 for Main Building and 2000 records for Hammet building. No records were provided for Tower building.

Furthermore, those reports indicated some repairs to be done and no follow-up was provided for those repairs.

The facility also did not have any policy and procedure or statistics in place regarding the frequency the test be conducted if not annually. Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

Findings were verified with Senior Associate Director Facilities.

D. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Tower Building.

Findings include:

On 04/23/14 at 12:15 PM during the tour of the Nursery and NICU on 8th floor -Tower Building, it was noted that the supplies closet did not have any sprinkler head. The tower building is a fully sprinklered building with date of certification of 2006.

It is to be noted that NFPA 13, Section 5-1.1, states that a building with sprinklers installed throughout is considered fully sprinklered.

Furthermore section 5-13.1.1* states that:
All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers.

Closets are part of the building structure, which have the walls, ceiling, and floor generally made of the same construction materials as the building. Closets are required to be sprinklered in a sprinklered building.


Findings were observed and verified with Senior Associate Director Facilities.

Based on document review and staff interview, the Main Building of the facility does not the three branches of generator divided into Life Safety, Critical and Equipment branch. The facility performs general anesthesia in its Main Building and has emergency generators installed in the facility and thus requires a Type I EES (essential electrical system). Furthermore the wiring of the electrical system at the panels on patient care floors in the Tower building (build in 2003) are not in compliance with the code, NFPA 99 3-4.

Findings include:

1. In an interview with Supervisor Electrician and Senior Associate Director Facilities on 04/28/14 at 2:00 PM, it was indicated that the wiring configuration in the Main Building of the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation and wiring of the generator branches into a life safety, critical, and equipment system was not done for the panels in Main building area and patient floors. Thus the three branches has mixed wiring for life safety, and critical in whatever panel it is present in the Main building facility and are not segregated into three branches.
The Senior Associate Director Facilities stated that this is an old building from 1950's which did not require three branches at the time of construction, however as per the Certificate of Need records with the Department of Health, the facility has had major work done in the building in terms of renovation, upgrade of electrical system and addition of wings in the last few years and hence compliance with NFPA 99 is required.

2. During tour of the Tower building and document review of the panel and switches between 04/24/14 to 04/25/14 between 11:00 AM to 3:30 PM it was observed that the some of the wiring for items required to be served by the Emergency System - Critical were not independent from wiring for items required to be served by the Emergency System - Life Safety Branch.

Examples include:
i. The Life Safety Panel on 8th floor - LSLP8 was serving circuits in room#s such as 806A, 800B, 816A and similar many other rooms.
ii. The Life Safety Panel on 1st floor - LSLP1 was serving circuits in room#s such as 184, 100, 166, 104 and similar many other rooms. Furthermore it was also noted to have refrigerator hooked on it.
iii. The Panel LSRP1 on 1st floor which was described by the staff to be a life safety panel did not have any directory and therefore it could not be determined what items were wired to this panel.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.


All above findings were verified with Senior Associate Director Facilities.



1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Based on observation, facility did not ensure that power strips are not used as a permanent source of power from an electrical receptacle.
Findings include
On 04/25/14 at 12:55 PM, during the tour of the Medical Intensive Care Unit-7th floor Tower building, it was observed that a power strip was installed in the Clean Utility Room. Two to three items were plugged in on the strip.
As per Senior Associate Director Facilities, the hospital realizes that there should be no use of power strips in the facility. However he did not know how and when this particular strip was installed in a way that it was serving as a solution for permanent electrical receptacle.
NFPA 70 states that Power strips may not be used as a substitute for adequate electrical outlets in a facility.

Findings were verified with Senior Associate Director Facilities and Nurse Manager of the unit.