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 not protected completely to meet minimum fire rated building construction of Type II (222).

The findings are:

During the survey, on 01/22/15 & 01/23/15 at between 12:00 PM to 2:15 PM, observations were made in the Mechanical room on 3rd floor and other floors where structural beams were visible from the floor level. 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 and thus exhibited big gaps devoid of fire spray.

Findings were verified with Interim Assistant Vice President 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, it was determined that the facility failed to ensure that fire/smoke barrier doors are designed and maintained to prevent and resist the passage of smoke.


The findings are:

During the tour of the facility from 01/20/15 to 01/22/15 between 11:00 AM to 4:00 PM, it was observed that the fire/smoke barrier doors did not close completely to resist the passage of smoke in case of fire.

Examples included, but were not limited to:

a) On 01/20/15 at 12:00 PM, it was observed that the fire/smoke doors (#2-6) on 2nd floor that lead towards the Operating Suite, were held open by means of electromagnetic devices. These doors, when released manually, did not close completely. A big gap was noted between the meeting edges of the doors.

b) On 01/20/15 at 2:00 PM it was observed that the fire/smoke doors (#B-CR 15) near the Main Central Sterile Processing area, are held open by means of electromagnetic devices. These doors, when released manually, did not close completely.

(c) On 01/22/15 at 11:00 AM it was observed that the fire/smoke doors (#3-2) on the 3rd floor, are held open by means of electromagnetic devices. These doors, when released manually, did not close completely.

Findings were verified with the Director of Environmental Health and Safety and the engineering staff escorting the surveyor during the survey.


2000 NFPA 101: 19.3.7.6, 8.3.4, 8.3.4.1

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:

1. On 01/28/15 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 date 07/2014 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.

The Director of Environmental Health and Safety (DEHS), was asked to provide documentation for semi-annual 30 minute discharge test of fire alarm batteries, whether the batteries are lead-acid type, and documentation for the Load Voltage Test.

The DEHS confirmed at 2:30 PM that the battery is lead-acid type. Information / verification for the semi-annual discharge tests and the load voltage test results were not provided.

Similar findings were noted in the December 2014 fire alarm reports for the out patient locations of Lefferts Avenue and Nostrand Avenue.

2. Furthermore, for the outpatient buildings (Lefferts & Nostrand) no information was provided for the the sensitivity test performance on all smoke detectors in accordance with NFPA 72.

Note: Section -7-3.2.1* NFPA 72 requires that detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.

All above findings were verified with the Director of Environmental Health and Safety (DEHS), and 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 01/28/15 at 11:45 AM, during the review of the Sprinkler Test report dated 12/29/14, it was noted that the report had many issues identified for correction/repair in the Sprinkler System. Director of Environmental Health and Safety (DEHS), was requested to provide the annual report prior to this sprinkler test report. The report dated 12/30/13 was provided and it indicated issues that are similar to those stated in the current report dated 12/29/14. These issues, a year after they appeared in the earlier report, remain unresolved. Examples of these issues include, but are not limited to:
i. Bullet #1n - PRV's on hose outlets need test and standpipes need flow test.
ii. Bullet #1r- No protection LL2-122B, LL2-109B, LL-109F, L2-305K, and etc.
iii. Table -2 Alarm lines needed
iv. Bullet #4a - Fire pump test header missing 2 caps in pump room.
v. Bullet #2b - Pharmacy has a 2-1/2" OS&Y valve stuck in closed position in broken handle.

Some of the issues identified, such as, sprinkler pendent dirty or plugged, waterflow alarms failing, and problem with inspector test valve, though they are showing up in both reports, the issues are occurring at a different location in the Sprinkler system.

The engineering staff and DEHS were not aware of recurring issues and indicated that some issues may have been resolved after the 12/30/13 Report, and they do not know why they are showing up in the 12/29/14 Report. The DEHS indicated that there is no comprehensive document or verification that indicates that all of the issues identified in the 12/30/13 were corrected.

2. On 01/28/15 at 12:30 PM, regarding the review of the five year 'Standpipe Hydrostatic test and Flow Test', the facility provided a certification dated 09/25/13 & 07/22/14. This certification or any other report did not have the information that the test was done for 2 hrs and at not less than 200 PSI. DEHS stated that this test is conducted in the presence of and witnessed by FDNY, and it is the facility's only proof of the test.

It is to be noted that the document clearly states that the 'test' is in accordance with the Department's / FDNY regulation and it does not state that the test is in lieu of / an alternative / an equivalent / for being 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."

3. On 01/29/15 at 12:00 PM, during documentation review for the sprinkler test for the outpatient clinic located in Nostrand Avenue, it was noted and verified by DEHS that there is no documentation or report available to show that the five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

The report dated 11/26/14 did not include the above information.

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.

All above findings were verified with DEHS and the engineering personnel present at the time of review.

Based on observation, facility did not ensure that the 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 01/20/15 to 01/30/15 between 10:30 AM to 3:45 PM, it was noted that in the various floors of the Main Building and in the Outpatient Clinic/Lefferts, 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 feet (60 inches).

Examples include, but are not limited to:

i. Extinguishers in the Postpartum/Nursery Unit on the 3rd floor were above 5 feet (ft.) in the corridors.
ii. Extinguisher near the Pediatric Unit Entrance door on the 4th floor was above 5 feet. Another extinguisher near room #A4-359 was noted installed more than 5 feet above floor.
iii. Extinguishers were noted to be above 5 feet in the corridors and entrance of the Lefferts Avenue out-patient clinic.

All findings were verified with Director of Environmental Health and Safety and Interim Assistant Vice President Design and Construction.

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. On 01/28/15 at 2:00 PM, during review of the last fire/smoke damper assessment of the facility dated 05/28/13, it was noted that there were many dampers that had deficiencies. A follow up report or work order that would show that corrective actions were taken by the facility was not available or presented to the Survey Team.

Examples include, but are not limited to:
i. Damper # 37FSDIS - Fan needs to be changed
ii. Damper # 90FSDIS - Damper failed to close.
iii. Damper # 55FSDIS - Replace homemade damper; actuator inside damper.
iv. Damper # 44FSDIS - Replace homemade damper.
v. Damper # 40AFSDIS - FSD not rated; replace.
vi. Damper # 42FSDIS - Unit not running.
vii. Damper # 46FSDIS - No end switch activation.
viii. Damper # 52FSDIS - Sealant used to seal duct; replace.
ix. Damper # 61FSDIS - No access to test heat element.
x. Damper # 38FSDIS - Damper bent; replace.
xi. Damper # 36FSDIS - Unit cannot be shut down.
2. During the inspection of the fire and smoke barriers in the facility on 01/22/15 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/smoke 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 that 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.

A few of the examples of fire retardant material around the ducts was related to the duct passing the fire/smoke barrier of the 3rd floor (near the Postpartum/Nursery Unit), barrier 3-370, 3-2, barriers on 4th floor, and other similar rated walls seen throughout the facility.

The facility did not consistently ensure that the ducts with fire/smoke dampers did not have their retaining angles sealed with fire caulking or sealant, which would compromise the fire damper UL listing as per UL 555. Also, one of the deficiencies in the damper report states that "Damper # 52FSDIS - Sealant used to seal duct; replace" which indicates that using sealant around duct can be an issue.

Findings were verified with the Interim Assistant Vice President Design & Construction , Director of Environmental Health and Safety and the engineering staff.

Based on observations and document review, the facility did not ensure that the bulk oxygen storage tanks were protected from the elements of hazard, and that the storage area was clear of debris.

Findings are:


During the tour of the Main Oxygen Bulk tank on 01/29/15 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 the liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily.

Findings were verified with Deputy Director of Nursing and Director of Environmental Health and Safety.

NFPA 99 4-3.1.2.2

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and floors were protected/sealed with a material capable of maintaining the fire/smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6 . Furthermore, the fire/smoke barriers were not maintained for its full integrity.

Findings include:

During the tour of the facility between 01/20/15 to 01/28/15 from 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 were also inspected for integrity.

It was noted that the fire/smoke barriers that were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes did not have complete seal all around to prevent passage of smoke from one compartment to the other or the devices used to prevent migration of smoke was not properly maintained.

Examples include, but are not limited to:

a. The HILTI sleeves in the fire/smoke barrier through which many cables were passing from one side of the barrier to the other, were noted as not closed to seal and prevent passage of smoke. An example was in the fire/smoke barrier wall # A3-369 and #3-2.

b. Gaps and big holes in the wall were noted in the Mechanical room #A3-384.

c. The conduits in electrical closet such as EC3-19, 8-424, 8-EC15 were noted penetrating the floor without any fire retardant sealing the opening.

Furthermore, the doors of the electrical closet through out the facility did not have any tag for the identification of the door's rating. As per NFPA 80 1999 section 1-5.1*, listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

These findings were verified with the Director of Environmental Health and Safety, Interim Assistant Vice President Design & Construction and other engineering staff present at the time of observation.

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.

A. Based on observation, document review and staff interview, the facility did not ensure that the TYPE 1 Essential Electrical System (EES) wiring for three branches of Emergency Generator was done as per NFPA 99 3.4.2.2.2 and thus did not ensure that anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch of Equipment Branch.


Findings include:

1. On 01/22/15, during the tour of the Transplant Unit- 8th floor of the facility, the Interim Assistant Vice President Design & Construction (IAVDC) was questioned regarding the location of the emergency electrical panels.

A panel board labeled EP #8B1 located in the electrical closet was told to be an emergency branch panel .There was no label or verification of which branch of the emergency generator is serving this panel.

In reviewing the directory it was noted that there was wiring for the receptacles on the panel along with lighting of corridor and radiant panels. If this was considered a Life Safety Branch panel (because it had corridor lighting) then it had a mixing of wiring with Critical Care Branch (which is for receptacles in patient rooms) and Radiant Panels (their purpose was not told to the surveyor)

Therefore, it was concluded that this panel has mixed wiring and is not wired as per TYPE 1 EES.

It was told to the surveyor that this Transplant unit is a newly renovated unit. The IAVDC stated that as far as he knows there are not three branches of emergency power for this unit, but the Neonatal Intensive Care unit on 3rd floor has three branches.

2. The directory of emergency panel LP-3LS was reviewed, and as per the Interim Assistant Vice President Design & Construction it was a Life Safety panel, but it had mixing of medical gas alarms and corridor lighting, with room receptacles, with roof fans which are supposed to be in a Life Safety panel, Critical Panel and Equipment Panel respectively.

All above findings were verified with and Director of Engineering.


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

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.

NOTE: 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.


B. Based on staff interview and document review, the facility could not verify that the emergency generators are tested in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110. Furthermore facility could not provide documented evidence for the maintenance program of the transfer switches.

Findings include.

1. 01/29/15 at 12:30 PM, during documentation review of the emergency generator monthly load test logs, it was noted that the logs did not include the information for time delays during testing.

Healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:

NFPA 110 (99) section 6-4.3
Load tests of generator sets shall include complete cold starts.

section 6-4.4
Time delays shall 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.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum

Therefore based on the review of facility's logs it could not be determined if the generators meet the above guidelines

Findings were verified with the Assistant Director Physical Plant Operations.

2. Facility was requested on 01/28/15 at 2:00 PM 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 the maintenance program they currently have through a contract with 'National Grid Management LLC' is followed by the facility, which includes checking for all parameters required by the code.

A. 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 01/28/15 at 2:00 PM, facility was requested to provide information for the critical and non-critical patient care equipment. 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 facility has "Servo-i" ventilators that have their preventive maintenance once a year. The Director of Bio-Med acknowledged that no electrical safety test was done in any other time of the year since it is a part of the preventive maintenance. Thus the 'Servo-i' ventilators 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 states:
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.

Furthermore, the facility's bio-medical preventive maintenance policy does not categorize equipment used in the facility under the three categories defined by NFPA 99 for their electrical safety test.

Findings were verified with the Director of Bio-Med Engineering.

B. 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 01/22/15 at 11:45 AM during the tour of the 8th floor-Transplant Unit, it was noted that the supplies closet did not have any sprinkler head. The suite as per floor plan is fully sprinklered and is a newly renovated suite.

It is to be noted that NFPA 13, 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 order for the building to be considered fully sprinklered.

Findings were observed and verified with and Director of Environmental Health and Safety.

C. Based on observation, facility did not ensure that the electrical panels on the floor and in the main electrical room are identified for the circuits served by emergency power system and specifically the branch it serves.


Findings include:

During the survey of the facility from 01/20/15 to 01/28/15 between 10:30 AM to 4:00 PM, electrical panels on different floors and in the main switch gear room in the basement were inspected, it was observed that the electrical panels were not conspicuously identified/labeled for the circuits served by the emergency power system and the branches. The distributions were not identified on the panel circuit directory.

NFPA 70 section 384-13 states that:
"All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors".


D. 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 01/29/15 at 3:30 PM, facility was requested to provide evidence that electrical receptacles in the patient care areas were tested.


The facility also did not have electrical testing report for the Transplant unit on 8th floor and Operating rooms.


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


"(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."

Based on observation and staff interview, the facility does not have the three branches of generator divided into Life Safety, Critical and Equipment branches. 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 Main Building are not in compliance with the code, NFPA 99 3-4.

Findings include:

1. In an interview with Interim Assistant Vice President Design & Construction on 01/23/15 at 3:00 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, critical and equipment in all panels present in the facility's Main building, and the wiring of the generator is not segregated into three branches.

The facility stated that this is an old building from the 1960's which probably 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, addition of Operating rooms, and other similar projects in the last few years and hence compliance with NFPA 99 is required.

2. During tour of the facility and document review of the panel and switches from 01/21/15 to 01/23/15 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.

Refer to Tag K 106

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

A. Based on observation and staff interview, the facility did not ensure that all electrical equipment in the facility was plugged into fixed wiring rather than moveable power taps (power strips) and extension cords, in accordance with the National Electrical Code (NFPA 70).
The findings are:
During the tour of the Outpatient facility at Lefferts Avenue on 01/130/15 at 1:00 PM, it was noted that in the Information Technology/Data closet, there were 4-5 items plugged into a power tap.
NOTE: National Electrical Code (NFPA-70) has specific requirements for the use of extension cords and power taps. Extension cords are not acceptable substitutes for the NEC-compliant fixed wiring of a structure such as a receptacle outlet.
Therefore, facility needs to justify the use of any power strips and extension cords that it plans to use. Furthermore, verification is required that use of power strips/taps will not cause trip or over load the electrical supply, and that the ones used are only UL 1363, 1449 2nd edition, or 46D0 approved power strips (those with over-current testing) .

NFPA 70 400-8, 210-20(b) (1) & (2) / 210-23
1999 NFPA 70 - National Electrical Code
Article 305 - Temporary Wiring, Section 305-2.


B. Based on observation, facility did not ensure that the electrical equipment in the facility is maintained free of damage.

Findings include:

On 01/23/15 at 12:15 PM, during the tour of the Neonatal Intensive Care Unit (NICU), it was observed that a portable x-ray machine was present in the NICU. This machine had a big portion of its corner damaged/broken which revealed the machines underneath structure.

As per NFPA 70 1999 Article 110-12. Mechanical Execution of Work
Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; cut; or deteriorated by corrosion, chemical action, or overheating.

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 Medical Intensive Care unit on 01/23/15 at 12:00 PM, it was noted that by Bay #9, the Alcohol Based Hand Rub (ABHR) dispenser was installed directly above an ignition source (i.e., electric light switches)

Findings were verified with the and the Director of Environmental and Safety.

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 not protected completely to meet minimum fire rated building construction of Type II (222).

The findings are:

During the survey, on 01/22/15 & 01/23/15 at between 12:00 PM to 2:15 PM, observations were made in the Mechanical room on 3rd floor and other floors where structural beams were visible from the floor level. 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 and thus exhibited big gaps devoid of fire spray.

Findings were verified with Interim Assistant Vice President 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, it was determined that the facility failed to ensure that fire/smoke barrier doors are designed and maintained to prevent and resist the passage of smoke.


The findings are:

During the tour of the facility from 01/20/15 to 01/22/15 between 11:00 AM to 4:00 PM, it was observed that the fire/smoke barrier doors did not close completely to resist the passage of smoke in case of fire.

Examples included, but were not limited to:

a) On 01/20/15 at 12:00 PM, it was observed that the fire/smoke doors (#2-6) on 2nd floor that lead towards the Operating Suite, were held open by means of electromagnetic devices. These doors, when released manually, did not close completely. A big gap was noted between the meeting edges of the doors.

b) On 01/20/15 at 2:00 PM it was observed that the fire/smoke doors (#B-CR 15) near the Main Central Sterile Processing area, are held open by means of electromagnetic devices. These doors, when released manually, did not close completely.

(c) On 01/22/15 at 11:00 AM it was observed that the fire/smoke doors (#3-2) on the 3rd floor, are held open by means of electromagnetic devices. These doors, when released manually, did not close completely.

Findings were verified with the Director of Environmental Health and Safety and the engineering staff escorting the surveyor during the survey.


2000 NFPA 101: 19.3.7.6, 8.3.4, 8.3.4.1

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:

1. On 01/28/15 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 date 07/2014 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.

The Director of Environmental Health and Safety (DEHS), was asked to provide documentation for semi-annual 30 minute discharge test of fire alarm batteries, whether the batteries are lead-acid type, and documentation for the Load Voltage Test.

The DEHS confirmed at 2:30 PM that the battery is lead-acid type. Information / verification for the semi-annual discharge tests and the load voltage test results were not provided.

Similar findings were noted in the December 2014 fire alarm reports for the out patient locations of Lefferts Avenue and Nostrand Avenue.

2. Furthermore, for the outpatient buildings (Lefferts & Nostrand) no information was provided for the the sensitivity test performance on all smoke detectors in accordance with NFPA 72.

Note: Section -7-3.2.1* NFPA 72 requires that detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method;
(2) Manufacturer's calibrated sensitivity test instrument;
(3) Listed control equipment arranged for the purpose;
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit to indicate if its sensitivity is outside its listed sensitivity range;
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction;
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and re-calibrated or be replaced.

All above findings were verified with the Director of Environmental Health and Safety (DEHS), and 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 01/28/15 at 11:45 AM, during the review of the Sprinkler Test report dated 12/29/14, it was noted that the report had many issues identified for correction/repair in the Sprinkler System. Director of Environmental Health and Safety (DEHS), was requested to provide the annual report prior to this sprinkler test report. The report dated 12/30/13 was provided and it indicated issues that are similar to those stated in the current report dated 12/29/14. These issues, a year after they appeared in the earlier report, remain unresolved. Examples of these issues include, but are not limited to:
i. Bullet #1n - PRV's on hose outlets need test and standpipes need flow test.
ii. Bullet #1r- No protection LL2-122B, LL2-109B, LL-109F, L2-305K, and etc.
iii. Table -2 Alarm lines needed
iv. Bullet #4a - Fire pump test header missing 2 caps in pump room.
v. Bullet #2b - Pharmacy has a 2-1/2" OS&Y valve stuck in closed position in broken handle.

Some of the issues identified, such as, sprinkler pendent dirty or plugged, waterflow alarms failing, and problem with inspector test valve, though they are showing up in both reports, the issues are occurring at a different location in the Sprinkler system.

The engineering staff and DEHS were not aware of recurring issues and indicated that some issues may have been resolved after the 12/30/13 Report, and they do not know why they are showing up in the 12/29/14 Report. The DEHS indicated that there is no comprehensive document or verification that indicates that all of the issues identified in the 12/30/13 were corrected.

2. On 01/28/15 at 12:30 PM, regarding the review of the five year 'Standpipe Hydrostatic test and Flow Test', the facility provided a certification dated 09/25/13 & 07/22/14. This certification or any other report did not have the information that the test was done for 2 hrs and at not less than 200 PSI. DEHS stated that this test is conducted in the presence of and witnessed by FDNY, and it is the facility's only proof of the test.

It is to be noted that the document clearly states that the 'test' is in accordance with the Department's / FDNY regulation and it does not state that the test is in lieu of / an alternative / an equivalent / for being 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."

3. On 01/29/15 at 12:00 PM, during documentation review for the sprinkler test for the outpatient clinic located in Nostrand Avenue, it was noted and verified by DEHS that there is no documentation or report available to show that the five (5) year internal inspections for obstructions on the sprinkler piping, alarm valves, and associated trim were conducted. Furthermore, no verification was presented to verify if the gauges were recalibrated or replaced in the past five years.

The report dated 11/26/14 did not include the above information.

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.

All above findings were verified with DEHS and the engineering personnel present at the time of review.

Based on observation, facility did not ensure that the 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 01/20/15 to 01/30/15 between 10:30 AM to 3:45 PM, it was noted that in the various floors of the Main Building and in the Outpatient Clinic/Lefferts, 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 feet (60 inches).

Examples include, but are not limited to:

i. Extinguishers in the Postpartum/Nursery Unit on the 3rd floor were above 5 feet (ft.) in the corridors.
ii. Extinguisher near the Pediatric Unit Entrance door on the 4th floor was above 5 feet. Another extinguisher near room #A4-359 was noted installed more than 5 feet above floor.
iii. Extinguishers were noted to be above 5 feet in the corridors and entrance of the Lefferts Avenue out-patient clinic.

All findings were verified with Director of Environmental Health and Safety and Interim Assistant Vice President Design and Construction.

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. On 01/28/15 at 2:00 PM, during review of the last fire/smoke damper assessment of the facility dated 05/28/13, it was noted that there were many dampers that had deficiencies. A follow up report or work order that would show that corrective actions were taken by the facility was not available or presented to the Survey Team.

Examples include, but are not limited to:
i. Damper # 37FSDIS - Fan needs to be changed
ii. Damper # 90FSDIS - Damper failed to close.
iii. Damper # 55FSDIS - Replace homemade damper; actuator inside damper.
iv. Damper # 44FSDIS - Replace homemade damper.
v. Damper # 40AFSDIS - FSD not rated; replace.
vi. Damper # 42FSDIS - Unit not running.
vii. Damper # 46FSDIS - No end switch activation.
viii. Damper # 52FSDIS - Sealant used to seal duct; replace.
ix. Damper # 61FSDIS - No access to test heat element.
x. Damper # 38FSDIS - Damper bent; replace.
xi. Damper # 36FSDIS - Unit cannot be shut down.
2. During the inspection of the fire and smoke barriers in the facility on 01/22/15 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/smoke 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 that 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.

A few of the examples of fire retardant material around the ducts was related to the duct passing the fire/smoke barrier of the 3rd floor (near the Postpartum/Nursery Unit), barrier 3-370, 3-2, barriers on 4th floor, and other similar rated walls seen throughout the facility.

The facility did not consistently ensure that the ducts with fire/smoke dampers did not have their retaining angles sealed with fire caulking or sealant, which would compromise the fire damper UL listing as per UL 555. Also, one of the deficiencies in the damper report states that "Damper # 52FSDIS - Sealant used to seal duct; replace" which indicates that using sealant around duct can be an issue.

Findings were verified with the Interim Assistant Vice President Design & Construction , Director of Environmental Health and Safety and the engineering staff.

Based on observations and document review, the facility did not ensure that the bulk oxygen storage tanks were protected from the elements of hazard, and that the storage area was clear of debris.

Findings are:


During the tour of the Main Oxygen Bulk tank on 01/29/15 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 the liquid oxygen tanks. Dead dried leaves are combustible and catch fire easily.

Findings were verified with Deputy Director of Nursing and Director of Environmental Health and Safety.

NFPA 99 4-3.1.2.2

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls and floors were protected/sealed with a material capable of maintaining the fire/smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6 . Furthermore, the fire/smoke barriers were not maintained for its full integrity.

Findings include:

During the tour of the facility between 01/20/15 to 01/28/15 from 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 were also inspected for integrity.

It was noted that the fire/smoke barriers that were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes did not have complete seal all around to prevent passage of smoke from one compartment to the other or the devices used to prevent migration of smoke was not properly maintained.

Examples include, but are not limited to:

a. The HILTI sleeves in the fire/smoke barrier through which many cables were passing from one side of the barrier to the other, were noted as not closed to seal and prevent passage of smoke. An example was in the fire/smoke barrier wall # A3-369 and #3-2.

b. Gaps and big holes in the wall were noted in the Mechanical room #A3-384.

c. The conduits in electrical closet such as EC3-19, 8-424, 8-EC15 were noted penetrating the floor without any fire retardant sealing the opening.

Furthermore, the doors of the electrical closet through out the facility did not have any tag for the identification of the door's rating. As per NFPA 80 1999 section 1-5.1*, listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

These findings were verified with the Director of Environmental Health and Safety, Interim Assistant Vice President Design & Construction and other engineering staff present at the time of observation.

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.

A. Based on observation, document review and staff interview, the facility did not ensure that the TYPE 1 Essential Electrical System (EES) wiring for three branches of Emergency Generator was done as per NFPA 99 3.4.2.2.2 and thus did not ensure that anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch of Equipment Branch.


Findings include:

1. On 01/22/15, during the tour of the Transplant Unit- 8th floor of the facility, the Interim Assistant Vice President Design & Construction (IAVDC) was questioned regarding the location of the emergency electrical panels.

A panel board labeled EP #8B1 located in the electrical closet was told to be an emergency branch panel .There was no label or verification of which branch of the emergency generator is serving this panel.

In reviewing the directory it was noted that there was wiring for the receptacles on the panel along with lighting of corridor and radiant panels. If this was considered a Life Safety Branch panel (because it had corridor lighting) then it had a mixing of wiring with Critical Care Branch (which is for receptacles in patient rooms) and Radiant Panels (their purpose was not told to the surveyor)

Therefore, it was concluded that this panel has mixed wiring and is not wired as per TYPE 1 EES.

It was told to the surveyor that this Transplant unit is a newly renovated unit. The IAVDC stated that as far as he knows there are not three branches of emergency power for this unit, but the Neonatal Intensive Care unit on 3rd floor has three branches.

2. The directory of emergency panel LP-3LS was reviewed, and as per the Interim Assistant Vice President Design & Construction it was a Life Safety panel, but it had mixing of medical gas alarms and corridor lighting, with room receptacles, with roof fans which are supposed to be in a Life Safety panel, Critical Panel and Equipment Panel respectively.

All above findings were verified with and Director of Engineering.


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

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.

NOTE: 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.


B. Based on staff interview and document review, the facility could not verify that the emergency generators are tested in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 and NFPA 110. Furthermore facility could not provide documented evidence for the maintenance program of the transfer switches.

Findings include.

1. 01/29/15 at 12:30 PM, during documentation review of the emergency generator monthly load test logs, it was noted that the logs did not include the information for time delays during testing.

Healthcare facilities must exercise their emergency generators under load at least monthly, and time delays must be set as follows:

NFPA 110 (99) section 6-4.3
Load tests of generator sets shall include complete cold starts.

section 6-4.4
Time delays shall 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.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum

Therefore based on the review of facility's logs it could not be determined if the generators meet the above guidelines

Findings were verified with the Assistant Director Physical Plant Operations.

2. Facility was requested on 01/28/15 at 2:00 PM 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 the maintenance program they currently have through a contract with 'National Grid Management LLC' is followed by the facility, which includes checking for all parameters required by the code.

A. 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 01/28/15 at 2:00 PM, facility was requested to provide information for the critical and non-critical patient care equipment. 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 facility has "Servo-i" ventilators that have their preventive maintenance once a year. The Director of Bio-Med acknowledged that no electrical safety test was done in any other time of the year since it is a part of the preventive maintenance. Thus the 'Servo-i' ventilators 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 states:
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.

Furthermore, the facility's bio-medical preventive maintenance policy does not categorize equipment used in the facility under the three categories defined by NFPA 99 for their electrical safety test.

Findings were verified with the Director of Bio-Med Engineering.

B. 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 01/22/15 at 11:45 AM during the tour of the 8th floor-Transplant Unit, it was noted that the supplies closet did not have any sprinkler head. The suite as per floor plan is fully sprinklered and is a newly renovated suite.

It is to be noted that NFPA 13, 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 order for the building to be considered fully sprinklered.

Findings were observed and verified with and Director of Environmental Health and Safety.

C. Based on observation, facility did not ensure that the electrical panels on the floor and in the main electrical room are identified for the circuits served by emergency power system and specifically the branch it serves.


Findings include:

During the survey of the facility from 01/20/15 to 01/28/15 between 10:30 AM to 4:00 PM, electrical panels on different floors and in the main switch gear room in the basement were inspected, it was observed that the electrical panels were not conspicuously identified/labeled for the circuits served by the emergency power system and the branches. The distributions were not identified on the panel circuit directory.

NFPA 70 section 384-13 states that:
"All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors".


D. 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 01/29/15 at 3:30 PM, facility was requested to provide evidence that electrical receptacles in the patient care areas were tested.


The facility also did not have electrical testing report for the Transplant unit on 8th floor and Operating rooms.


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


"(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."

Based on observation and staff interview, the facility does not have the three branches of generator divided into Life Safety, Critical and Equipment branches. 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 Main Building are not in compliance with the code, NFPA 99 3-4.

Findings include:

1. In an interview with Interim Assistant Vice President Design & Construction on 01/23/15 at 3:00 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, critical and equipment in all panels present in the facility's Main building, and the wiring of the generator is not segregated into three branches.

The facility stated that this is an old building from the 1960's which probably 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, addition of Operating rooms, and other similar projects in the last few years and hence compliance with NFPA 99 is required.

2. During tour of the facility and document review of the panel and switches from 01/21/15 to 01/23/15 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.

Refer to Tag K 106

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

A. Based on observation and staff interview, the facility did not ensure that all electrical equipment in the facility was plugged into fixed wiring rather than moveable power taps (power strips) and extension cords, in accordance with the National Electrical Code (NFPA 70).
The findings are:
During the tour of the Outpatient facility at Lefferts Avenue on 01/130/15 at 1:00 PM, it was noted that in the Information Technology/Data closet, there were 4-5 items plugged into a power tap.
NOTE: National Electrical Code (NFPA-70) has specific requirements for the use of extension cords and power taps. Extension cords are not acceptable substitutes for the NEC-compliant fixed wiring of a structure such as a receptacle outlet.
Therefore, facility needs to justify the use of any power strips and extension cords that it plans to use. Furthermore, verification is required that use of power strips/taps will not cause trip or over load the electrical supply, and that the ones used are only UL 1363, 1449 2nd edition, or 46D0 approved power strips (those with over-current testing) .

NFPA 70 400-8, 210-20(b) (1) & (2) / 210-23
1999 NFPA 70 - National Electrical Code
Article 305 - Temporary Wiring, Section 305-2.


B. Based on observation, facility did not ensure that the electrical equipment in the facility is maintained free of damage.

Findings include:

On 01/23/15 at 12:15 PM, during the tour of the Neonatal Intensive Care Unit (NICU), it was observed that a portable x-ray machine was present in the NICU. This machine had a big portion of its corner damaged/broken which revealed the machines underneath structure.

As per NFPA 70 1999 Article 110-12. Mechanical Execution of Work
Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; cut; or deteriorated by corrosion, chemical action, or overheating.