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Based on observation in the presence of facility director of engineering, and the Associate Director of Safety, the facility did not ensure that the fire doors had positive latch as required.

Findings include:

During a tour of the Gillman building on the afternoon of 2/6/2012, the fire door of first floor of the building- stair case A did not have positive latch as required for the fire doors.

Based on observation and staff interview, it was determined that the facility did not ensure that the vertical openings are enclosed with construction having a fire resistance rating of at least one hour in accordance with 8.2.5.6. 19.3.1.1.

Findings include:

1. The electric room G 876 on the 8th floor was observed to have penetrations around pipes on the ceiling and conduits that were not sealed with fire stops.

This observation was made in the presence of the Director of Engineering and the Associate Director of Safety.

This observation was made in the presence of the Director of Engineering and the Associate Director of Safety on the afternoon of 2/6/2012.

Based on observation and staff interview, the hospital did not ensure that exit components are enclosed construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings include:

1. The fire smoke door separating Gellman building from the new building had a gap approximately 1 inch between the two leaflets of the door and underneath the door which permit the passage of smoke between the two buildings.

2. The smoke and fire door between Gellman building and Aaron building next to room G665 was found to have a gap that exceeded 1/8 of inch and permit the passage of smoke between the two buildings.

3. The fire and smoke door that separates the Aaron building and the new building in the back of the pediatric department was found to have a gap that was approximately 1 inch. This gap permits the passage of smoke between the two buildings.

4. The smoke and fire door of Kronish building 3rd floor was observed to have a gap that exceeds 3/4 inches between the door and the floor and another gap that was >1/8 of inch between the two leaves of the door.

5. There was a penetration in the smoke and fire rated wall above the fire and smoke door of Kronish building (K3) next to staff lounge room 314.

All the above findings were identified in the presence of the Director of Engineering and were brought to the attention of the facility's leadership during the exit conference.

Based on document review and interview with the Associate Director of Safety the hospital did not conduct site specific fire drills for the Operative Suites.

Based on document review and staff interview, the facility did not ensure that the fire alarm system is well maintained and deficiencies identified during the system testing during the year of 2011 are corrected in timely manner.

Findings include:

1. Review of the Fire Alarm testing report of 5/20/2011 revealed that the ACME coded pull station (178-33-SA) near second floor nursing station did not send the proper code to panel. This deficiency was not corrected as of 2/6/2012.

2. Review of the Fire Alarm testing report of 1/27/2011 revealed that the conventional fire alarm control panel on the first floor O/S stair B was not connected to any remote station. This deficiency was not corrected as of 2/6/2012.

3. Review of the Fire Alarm and smoke detector testing report on 6/6/, 3/10, 9/13 and 5/14/2011 revealed that the smoke detector (serial # 634 on 6th floor, room 634) was heavily damaged and needed replacement. This deficiency was not corrected as of 2/6/2012.

4. Many smoke detectors were not tested on various testing reports because of no access to them. Examples included but were not limited to the following:

a. Detector 135 R serial # 5-2-9 on the 2nd floor I/S room 208 was not tested because of no access on 5/26/11, 12/7/10, 9/7/10 and 5/21/10.

b. Detector 135 R serial # 5-2-3 on the 2nd floor room 203 was not tested because of no access on 5/26/2011, 12/07/10, 9/7/10 and 5/21/2010.

Based on observation in the presence of facility director of engineering, and the Associate Director of Safety, the facility did not ensure that the fire doors had positive latch as required.

Findings include:

During a tour of the Gillman building on the afternoon of 2/6/2012, the fire door of first floor of the building- stair case A did not have positive latch as required for the fire doors.

Based on observation and staff interview, it was determined that the facility did not ensure that the vertical openings are enclosed with construction having a fire resistance rating of at least one hour in accordance with 8.2.5.6. 19.3.1.1.

Findings include:

1. The electric room G 876 on the 8th floor was observed to have penetrations around pipes on the ceiling and conduits that were not sealed with fire stops.

This observation was made in the presence of the Director of Engineering and the Associate Director of Safety.

This observation was made in the presence of the Director of Engineering and the Associate Director of Safety on the afternoon of 2/6/2012.

Based on observation and staff interview, the hospital did not ensure that exit components are enclosed construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings include:

1. The fire smoke door separating Gellman building from the new building had a gap approximately 1 inch between the two leaflets of the door and underneath the door which permit the passage of smoke between the two buildings.

2. The smoke and fire door between Gellman building and Aaron building next to room G665 was found to have a gap that exceeded 1/8 of inch and permit the passage of smoke between the two buildings.

3. The fire and smoke door that separates the Aaron building and the new building in the back of the pediatric department was found to have a gap that was approximately 1 inch. This gap permits the passage of smoke between the two buildings.

4. The smoke and fire door of Kronish building 3rd floor was observed to have a gap that exceeds 3/4 inches between the door and the floor and another gap that was >1/8 of inch between the two leaves of the door.

5. There was a penetration in the smoke and fire rated wall above the fire and smoke door of Kronish building (K3) next to staff lounge room 314.

All the above findings were identified in the presence of the Director of Engineering and were brought to the attention of the facility's leadership during the exit conference.

Based on document review and interview with the Associate Director of Safety the hospital did not conduct site specific fire drills for the Operative Suites.

Based on document review and staff interview, the facility did not ensure that the fire alarm system is well maintained and deficiencies identified during the system testing during the year of 2011 are corrected in timely manner.

Findings include:

1. Review of the Fire Alarm testing report of 5/20/2011 revealed that the ACME coded pull station (178-33-SA) near second floor nursing station did not send the proper code to panel. This deficiency was not corrected as of 2/6/2012.

2. Review of the Fire Alarm testing report of 1/27/2011 revealed that the conventional fire alarm control panel on the first floor O/S stair B was not connected to any remote station. This deficiency was not corrected as of 2/6/2012.

3. Review of the Fire Alarm and smoke detector testing report on 6/6/, 3/10, 9/13 and 5/14/2011 revealed that the smoke detector (serial # 634 on 6th floor, room 634) was heavily damaged and needed replacement. This deficiency was not corrected as of 2/6/2012.

4. Many smoke detectors were not tested on various testing reports because of no access to them. Examples included but were not limited to the following:

a. Detector 135 R serial # 5-2-9 on the 2nd floor I/S room 208 was not tested because of no access on 5/26/11, 12/7/10, 9/7/10 and 5/21/10.

b. Detector 135 R serial # 5-2-3 on the 2nd floor room 203 was not tested because of no access on 5/26/2011, 12/07/10, 9/7/10 and 5/21/2010.