HospitalInspections.org

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1. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that corridor door openings were not provided with transfer grills. Transfer grills, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings:

On 07/15/14 at 10:47AM, a louvered transfer grill was found in a corridor door (e.g., Main Building 1st Floor corridor Information Technology Closet located by the entrance to the Chapel). As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.4

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that clearance between the bottom of corridor doors and the floor did not exceed one (1) inch.

Findings:

On 07/14/14 at 2:46PM, an approximately one and one-half (1½) inch high cap was found between the bottom of a corridor door from the 4th Floor Main Building PACU and the floor. Openings at the bottom of corridor doors are limited to a maximum of one (1) inch in height to help prevent the transfer of smoke and other products of combustion in the event of a fire. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.1

10NYCRR, 405.24(b), 711.2(a)(1)


3. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings include:

(a) On 07/15/14 at 10:35AM, the inactive leaf to a set of double doors to a small Storage Closet on the 1st Floor of the Main Building (in the corridor outside of the Endoscopy Suite) was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

(b) On 07/15/14 at 3:20PM, the inactive leaf to a set of double doors to an Electrical Equipment Closet on the 5th Floor of the North Pavilion (vicinity of Room NP 552) was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all vertical penetrations were appropriately sealed.

Findings:

(a) On 07/16/14 at 8:10AM, two (2) partially sealed vertical conduit penetrations were noted in an Electrical Equipment Closet on the 3rd Floor of the Potter Pavilion (vicinity of Room 370). As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.
Corrected onsite.

(b) On 07/16/14 at 10:19AM, a partially sealed vertical cable penetration was noted in the floor on the Winthrop Pavilion 2nd Floor Non-Invasive Procedure Patient Prep Room. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.
Corrected onsite.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5

10NYCRR, 405.24(b), 711.2(a)(1)
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1. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that internally illuminated exit directional signs were maintained in an operational condition.

Findings:

On 07/14/14 at 10:53AM, the light bulbs inside an exit sign on the 5th Floor of the Hoag Pavilion (on wall above smoke barrier door #382 and near Room 511) were found to not be working at the time of the inspection. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10.5.2

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that an exit sign, complying with 7.10.3, with a directional indicator showing the direction of travel, was placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

On 07/15/14 at 11:25AM, signage that would indicate the direction of travel to the second means of egress in the Main Building Lover Level Employee Cafeteria was found to be missing. Additional exit directional signage shall be installed near the Cashier's Station.

As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10.2

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that existing smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating and that duct penetrations that were provided with smoke dampers were properly installed.

Findings:

(a) On 07/14/14 at 12:05PM, a duct penetration of a 2nd Floor smoke barrier wall (vicinity of Bay 1 in the Hoag 2 Critical Care Unit) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles. Firestopping material may, when exposed to the heat of a fire, expand and could crush the duct and prevent the fire/smoke damper within the duct from operating properly. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have this duct penetration sealed with the appropriate materials as soon as possible.

(b) On 07/14/14 at 12:30PM, a duct penetration of a 1st Floor smoke barrier wall (vicinity of Hoag Pavilion Room 109 on the corridor side of the smoke barrier wall) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

(c) On 07/14/14 at 12:32PM, a duct penetration of a 1st Floor smoke barrier wall (vicinity of Hoag Pavilion Nourishment Room 109) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles.

(d) On 07/14/14 at 3:00PM, an approximately two and one-half (2½) inch by five (5) inch hole was noted in a smoke barrier wall (vicinity of the Step-Down PACU on the 4th Floor of the Main Building. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have this hole sealed with the appropriate materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all doors to smoke barriers were provided with an approved self-closing or automatic-closing device.

Findings:

(a) On 07/14/14 at 11:51AM, a smoke barrier door (i.e., the door to the Staff Toilet in Smoke Compartment 2.1 on the 2nd Floor of the Hoag Pavilion) was noted to lack a self-closing device or approved automatic closing device.

(b) On the afternoon of 07/14/14, smoke barrier doors to Rooms 104, 106, 107, 108 and 109 on the 1st Floor of the Hoag Pavilion were noted to lack self-closing devices or approved automatic closing devices.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.6, 8.3.4

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors and enclosed in at least one (1) hour fire resistance rated enclosure walls.

Findings:

(a) On 07/16/14 at 8:20AM, the door to a bathroom that had been converted into a Storage Room on the 3rd Floor of the Potter Pavilion (near the connecting bridge to the Winthrop Pavilion) was found to lack a required self-closing device.

(b) On 07/16/14 at 8:34AM, the door to a Patient Lounge that had been converted into a Storage Room on the 3rd Floor of the North Pavilion was found to lack a required self-closing device and was not a three-quarter (¾) hour fire resistance rated door assembly.

(c) On 07/16/14 at 9:55AM, the door to a bathroom that had been converted into a Storage Room on the 2nd Floor of the Potter Pavilion (near the connecting bridge to the Winthrop Pavilion) was found to lack a required self-closing device.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.2.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all exit staircases were provided with guards installed in accordance with Life Safety Code requirements for existing staircases.

Findings:

On 07/15/14 at 3:15PM, sixteen (16) inch wide openings were noted between intermediate rails on handrail guards in the North Exit Stair in the 5th Floor of North Pavilion Building. Open guards shall have intermediate rails or an ornamental pattern such that a sphere four (4) inches in diameter cannot pass through any opening up to a height of thirty-four (34) inches. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.3, 7.2.2.4.6

10NYCRR, 405.24(b), 711.2(a)(1)
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Based observations and staff interview during the Federal Recertification Survey, the facility did not ensure that all means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

On 07/16/14 at 12:12PM, Cleaning / Housekeeping Department supplies were found to be improperly stored within a Winthrop Pavilion lower level exit stair enclosure (the "Center" exit stair). These materials were stored directly underneath the exit staircase. As per concurrent interview with the facility's Vice President of Engineering & Facilities, these items are not allowed to be stored in an exit enclosure. He took immediate corrective action and removed these materials from this exit staircase.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.1, 7.1.10.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that horizontal exits were in compliance with the requirements of 7.2.4.

Findings:

(a) On 07/15/14 at 3:39PM, an unsealed cable penetration was noted in a two (2) hour fire resistant rated combination horizontal exit fire barrier / smoke barrier in the vicinity of a SICU (Surgical Intensive Care Unit) Equipment Storage Room on the 4th Floor of the Potter Pavilion.

(b) On 07/16/14 at 8:52AM, a duct penetration of a two (2) hour fire resistant rated horizontal exit fire barrier (above cross-corridor doors near Room 335) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles. This two (2) hour fire resistant rated horizontal exit fire barrier is located between the 3rd Floor of the Potter Pavilion and the 3rd Floor of the North Pavilion.

(c) On 07/16/14 at 8:55AM, a three-quarter (¾) hour fire resistance rated door assembly was noted to be used in a two (2) hour fire resistant rated horizontal exit fire barrier (vicinity of Potter 3 On-Call Room). This two (2) hour fire resistant rated horizontal exit fire barrier is located between the 3rd Floor of the Potter Pavilion and the 3rd Floor of the North Pavilion.

(d) On 07/16/14 at 8:57AM, a three-quarter (¾) hour fire resistance rated door assembly was noted to be used in a two (2) hour fire resistant rated horizontal exit fire barrier (vicinity of Potter 3 Surgical On-Call Room located near Room 336). This two (2) hour fire resistant rated horizontal exit fire barrier is located between the 3rd Floor of the Potter Pavilion and the 3rd Floor of the North Pavilion.

(e) On 07/16/14 at 10:28AM, two (2) pipes were found to have been incorporated in the construction of the two (2) hour fire resistant rated horizontal exit fire barrier (in a wall in the vicinity of the cross-corridor doors near North Pavilion Room 240 and a 2 Potter Pavilion Storage Room. This two (2) hour fire resistant rated horizontal exit fire barrier is located between the 2nd Floor of the Potter Pavilion and the 2nd Floor of the North Pavilion.

(f) On 07/16/14 at 10:33AM, a three-quarter (¾) hour fire resistance rated door assembly was noted to be used in a two (2) hour fire resistant rated horizontal exit fire barrier (vicinity of Potter 2 Staff Locker Room). In addition, numerous unsealed and partially sealed penetrations were noted on one (1) side of the above-mentioned fire barrier wall in the Potter 2 Staff Locker Room. This two (2) hour fire resistant rated horizontal exit fire barrier is located between the 2nd Floor of the Potter Pavilion and the 2nd Floor of the North Pavilion.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.2.5, 7.2.4

10NYCRR, 405.24(b), 711.2(a)(1)
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1. Based on observations, record review and staff interview during the Federal Recertification Survey, the facility's Fire Plan failed to adequately address evacuation of smoke compartments.

Findings:

On the afternoon of 07/14/14, it was noted that smoke barrier walls on the 1st Floor of the Hoag Pavilion were arranged so that Rooms 104, 106, 107, 108 and 109 were provided with a single door opening into the adjacent smoke compartment. This configuration required that the rooms be evacuated in the event of a directed evacuation of either smoke compartment. The facility shall either reroute the smoke barriers or address this issue in the facility's fire plan. As per concurrent interviews with the facility's Director of Engineering, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.2.2(6)

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations, record review and staff interview during the Federal Recertification Survey, the facility's Life Safety drawings do not accurately reflect the actual arrangement of suites and exit access corridors within the facility.

Findings:

On 07/15/14 at 9:50AM, it was noted that a two (2) bay Patient Holding Area that was provided with piped-in medical gases in the 2 Main Special Procedures Area were open to the "corridor" and concurrent review of the facility Life Safety drawing "WUH-SOC-02" dated 07/11/14 indicate that this area is an exit access corridor. Life Safety Code Section 19.3.6.1 does not permit Patient Care Areas to be open to a corridor. Further observations of the design of this space revealed that it is actually a suite rather than an exit access corridor arrangement as indicated on the Life Safety drawings. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have the Life Safety Plan updated to reflect that this space is part of a suite and not part of an exit access corridor.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.7.2.2

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that fire alarm system initiating devices (e.g., smoke detectors) were properly maintained.

Findings:

(a) On 07/14/14 at 10:20AM, a heavy build-up of a black colored, soot-like substance and dust were noted on a ceiling-mounted smoke detector (Device #1727) in the 7th Floor Hoag Pavilion Elevator Machine Room.

(b) On 07/15/14 at 2:16AM, a smoke detector in the Gardner Pavilion 3rd Floor combination Linen Chute / Information Technology Equipment Room was found to have been improperly installed attached to overhead wires rather than to the ceiling of this room.

(c) On 07/15/14 at 2:25AM, a smoke detector in the Gardner Pavilion 2nd Floor combination Linen Chute / Information Technology Equipment Room was found to have been improperly installed attached to overhead wires rather than to the ceiling of this room.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.4.1, 9.6, NFPA 72-1999 National Fire Alarm Code: 7-1.1.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

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

(a) On 07/14/14 at 11:52AM, a Staff Toilet Room in Smoke Compartment 2.1 on the 2nd Floor of the Hoag Pavilion was noted to lack a sprinkler.

(b) On 07/15/14 at 10:44AM, an Electrical Closet on the 1st Floor of the Main Building was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in Electrical Equipment Rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction.

(c) On 07/15/14 at 10:47AM, an Information Technology Equipment Closet on the 1st Floor of the Main Building was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in Electrical Equipment Rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction.

(d) On 07/15/14 at 11:10AM, an Electrical Equipment Room in the vicinity of the 1st Floor Emergency Department Fast Track Area was found to lack sprinkler protection and would not be eligible for the exception for having a two (2) hour fire resistance rated enclosure due to an unsealed conduit penetration.

(e) On 07/15/14 at 3:47PM, an Information Technology Equipment Closet on the 4th Floor of the North Pavilion was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in Electrical Equipment Rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction.

(f) On 07/16/14 at 8:31AM, an Information Technology Equipment Closet on the 3rd Floor of the North Pavilion (vicinity of Room 352) was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in Electrical Equipment Rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction.

(g) On 07/16/14 at 8:47AM, an Electrical Equipment Closet on the 3rd Floor of the North Pavilion (vicinity of Room 335) was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in electrical equipment rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction. For example, only a three-quarter (¾) hour fire resistance door assembly was provided.

(h) On 07/16/14 at 10:54AM, an Information Technology Equipment Closet on the 2nd Floor of the North Pavilion (vicinity of the Nursing Station) was found to lack required sprinkler protection and would not meet the listed exception in NFPA 13 for the installation of sprinklers in Electrical Equipment Rooms because this room is not enclosed in at least two (2) hour fire resistance rated construction.

(i) On 07/16/14 at 1:20PM, an exit access aisle within the North Pavilion Lower Level Labor & Delivery Department On-Call Room Suite was found to lack sprinkler protection.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.1.1.4.5, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1, 5-13.6

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and/or maintained free of foreign material.

Findings:

(a) On 07/14/14 at 1:09PM, a foreign material (e.g., a piece of plastic film / wrapping material) was noted on the operable parts of a sprinkler in Hoag Pavilion Lower-Level Machine Room 32.
Corrected onsite.

(b) On 07/14/14 at 2:38PM, the escutcheon cover plate of a recessed sprinkler in a 4th Floor Main Building Storage Room (by the PACU {Post Anesthesia Care Unit}) was found to be missing.

(c) On 07/15/14 at 8:38AM, a foreign material (e.g., paint) was noted on the escutcheon cover plate of a recessed sprinkler in 3 Main Observation Unit Suite #301.

(d) On 07/15/14 at 10:03AM, the escutcheon cover plate of a recessed sprinkler in a 2nd Floor Main Building Storage Closet in the Special Procedures Suite was found to be missing.

(e) On 07/15/14 at 10:50AM, the escutcheon cover plate of a recessed sprinkler in a 1st Floor Main Building in the Gift Shop Storage Room was found to be missing.

(f) On 07/15/14 at 11:42AM, the escutcheon cover plate of a recessed sprinkler in the Main Building Lower Level Cyberknife Control Room was found to be missing.

(g) On 07/15/14 at 12:01PM, a light fixture in the Main Building Lower Level Soiled Linen Chute Discharge Room was found to have been installed adjacent to a sprinkler in this room and would disrupt the development of the sprinkler water discharge pattern.

(h) On 07/15/14 at 2:50PM, a ceiling tile was noted to be missing in a 1st Floor Ambulatory Surgery Unit Building Telephone Equipment Room that was protected by a recessed sprinkler. The integrity of the suspended ceiling assembly needs to be maintained to help to ensure the proper operation of the sprinkler.

(i) On 07/16/14 at 8:42AM, the escutcheon cover plate of a recessed sprinkler in a 3rd Floor North Pavilion Telephone Closet (near Room 347) was found to be missing.

(j) On 07/16/14 at 11:01AM, an sprinkler system inspectors test valve in a 2nd Floor North Pavilion Housekeeping Closet lacked required identification signage. All control, drain, and test connection valves are required to be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

(k) On 07/16/14 at 12:28PM, cables were found to have been improperly twist-tied onto sprinkler piping in Potter Pavilion Lower Level U.P.S. Equipment Room 1.

(l) On 07/16/14 at 12:39AM, a pendent sprinkler in a North Pavilion Lower Level Elevator Machine Room (located near the Soiled Linen Chute Discharge Room) was found to be heavily dust-laden.

(m) On 07/16/14 at 12:55PM, a pendant sprinkler was found to have been impurely installed in the upright position in North Pavilion Lower Level Machine Room 11.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that portable fire extinguishers were installed in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

Findings:

(a) On 07/14/14 at 12:43PM, the top of a portable "K" type fire extinguisher in the Lower Level Kitchen on the Hoag Pavilion was noted to be installed so that the top of the fire extinguisher was approximately seventy-two (72) inches above the floor. As per NFPA 10 Section 1-6.10, portable fire extinguishers that are less than forty (40) pounds in weight (such as the one in the kitchen) are to be installed so that the top of the fire extinguisher is not more than sixty (60) inches above the floor.

(b) On 07/15/14 at 3:34PM, a fire extinguisher that was stored in a recessed cabinet in a wall of the 4th Floor of the Potter Pavilion (near the entrance to the SICU) was noted to lack a required identification sign. When the physical location of a portable fire extinguisher is not readily visible another form of location identification (e.g., signage) is required.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.6, 9.7.4.1, NFPA 10-1998 Standard for Portable Fire Extinguishers: 1-6.10, 1-6.3, 1-6.6

10NYCRR, 405.24(b), 711.2(a)(1)
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1. Based on record review and staff interviews during the Federal Recertification Survey, the facility did not ensure that all cooking facilities were protected in accordance with applicable requirements. Specific reference is made to the lack of monthly visual inspections for the following items:

(a) The extinguishing system is in its proper location.

(b) The manual actuators are unobstructed.

(c) The tamper indicators and seals are intact.

(d) The maintenance tag or certificate is in place.

(e) No obvious physical damage or condition exists that might prevent operation.

(f) The pressure gauge(s), if provided, is in operable range.

(g) The nozzle blow off caps are intact and undamaged.

(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

Findings:

On the afternoon 07/14/14, review of monthly inspection tags in the Hoag Pavilion Lower Level Kitchen / Food Preparation Area and the Main Building Lower Level Employee Cafeteria Food Preparation Area revealed that the facility had not conducted required monthly visual inspections of wet chemical extinguishing systems provided in both of these locations during the month of June, 2014. As per concurrent interviews with the facility's Director of Engineering, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.2.1, NFPA 17A, Standard for Wet Chemical Extinguishing Systems: 5-2

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations and staff interview during the Federal Recertification Survey, the facility did not ensure that required placards identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system were conspicuously placed near each portable fire extinguisher in cooking areas.

Findings:

On 07/14/14 at 1:00PM, the facility was found to lack the required placard (sign) identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system near the portable "K" type fire extinguisher in the Main Building Lower Level Employee Cafeteria Food Preparation Area. The required placard shall state "WARNING: In case of appliance fire use this extinguisher after fixed suppression system has been used". As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have the required placard installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 7-2.1.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that Soiled Linen Chute Discharge Rooms were maintained in accordance with applicable Life Safety Code and NFPA 82, Standard on Incarcerators and Waste and Linen Handling Systems and Equipment.

Findings:

On 07/15/14 at 12:01PM, the fusible link fire damper that was supposed to be used to hold open an automatically closing fire door at the bottom of the soiled linen chute in the Main Building Lower Level Soiled Linen Chute Discharge Room was found to be missing and the door was found to be improperly held open by a small putty knife. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.4, 9.5.2, NFPA 82, Standard on Incarcerators and Waste and Linen Handling Systems and Equipment
10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observations and staff interviews during the Federal Recertification Survey, the facility did not ensure that electrical fixtures in oxygen storage locations were mounted at least sixty (60) inches above the finished floor as a precaution against their physical damage.

Findings:

On 07/16/14 at 11:57AM, a duplex electrical outlet in an Oxygen Cylinder Storage Room on the 1st Floor of the Winthrop Pavilion was installed at a height of fifty-two (52) inches above the floor. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999 Standard for Health Care Facilities: 4-3.1.1.2 (a) (4), (c)

10NYCRR, 405.24(b), 711.2(a)(1)
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1. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that the arrangements of all means of egress in the facility were in accordance with NFPA 101-2000 Section 19.2.5 for Existing Health Care Occupancies.

Findings:

On 07/14/14 at 11:10AM, it was noted that a designated (by posted exit directional signage) means of exit access from a Hoag Pavilion exit access corridor on the 3rd Floor were directed through intervening rooms or spaces (e.g., the ICU Suite). Exit access corridors are required to provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.5.9, 7.4, 7.5

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that existing hazardous areas in the facility that were designated as Business Occupancy Areas were enclosed in smoke resistant partitions or provided with fire resistance rated where required (e.g., high hazard areas).

Findings:

(a) On 07/14/14 at 1:10PM, a door from Hoag Pavilion Lower Level Mechanical Room 32 that opens into an exit access corridor was found to have a louvered air transfer grill. In the event of a fire in this mechanical space, this grill would allow smoke to transfer into this exit access corridor. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

(b) On 07/15/14 at 11:34AM, a Main Building Lower Level High Hazardous Storage Room was found to have at least thirty (30) gallons of a combustible liquid (e.g., alcohol based hand sanitizer) stored in this room and the room was found to not meet the requirements for a high-hazardous storage room. Specific reference is made to the lack of two (2) hour fire resistance rated walls (the walls in the room were found to not extend past the suspended ceiling assembly), the lack of an approved self-closing device on the active leaf of the door to this room and the lack of an automatic flush-bolt or other approved latching mechanism on the inactive leaf of the door. In addition, it was unclear if the sprinkler system in this room was designed for high hazard area. The facility's Vice President of Engineering & Facilities, took immediate corrective action by removing the containers of alcohol based sanitizers and moving them to a more appropriate storage location.

(c) On 07/16/14 at 12:10PM, the door to the Operating Room Storage Room in the 1st Floor of the Winthrop Pavilion was noted to lack a required self-closing device. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.3.2.1, 39.2.2.2, 8.4.1.1, 4.6.1.2, 8.2.4.1.1, 8.2.4.3.1, NFPA 30, Flammable and Combustible Liquids Code

10NYCRR, 405.24(b), 711.2(a)(1)


3. Based on observations and interview during the Federal Recertification Survey, the facility failed to ensure that exit stairs that continue beyond the level of exit discharge were interrupted at the level of discharge by partitions, doors, or other effective means.

Findings:

On 07/15/14 at 10:27AM, the Main Building West Exit Staircase was found to continue more than one-half (1/2) story beyond the floor of exit discharge (1st Floor) and was not interrupted at the level of discharge by a partition, door, or other effective physical barrier. As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.7, 7.7.3

10NYCRR, 405.24(b), 711.2(a)(1)


4. Based on observations during the Federal Recertification Survey, the facility failed to ensure that all assembly use areas were in compliance with all Life Safety Code requirements.

Findings:

(a) On 07/15/14 at 11:25AM, two (2) of two (2) Cashier Stations in the Main Building Lower Level Staff Cafeteria were located in such a manner that they each reduced the width of exit access aisles located next to each of these two (2) stations from approximately thirty-two (32) inches wide to approximately eighteen (18) inches wide.

(b) On 07/15/14 at 11:28AM, one (1) of the two (2) means of egress that serve the Main Building Lower Level Staff Cafeteria (which has seating for one hundred eight {108} occupants) was not provided with panic hardware on the egress side of the door.

As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 13.2.2.2.3, 13.2.5, 7.5.2, 7.1.10

10NYCRR, 405.24(b), 711.2(a)(1)


5. Based on observations and interview during the Federal Recertification Survey, the facility failed to ensure that all sleeping rooms (i.e., Lodging and Rooming House occupancies) that would require a smoke detector were provided with one.

Findings:

On 07/16/14 at 8:55AM, an On-Call Physician Sleeping Room located on the 3rd Floor of the Potter Pavilion was found to lack a required smoke detector in the room. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42CFR 482.41(b), NFPA 101-2000: 19.1.2, 6.1.14, 26.3.3.5

10NYCRR, 405.24(b), 711.2(a)(1)


6. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Multi-Specialty Care Building located at 120 Mineola Boulevard, Mineola, New York. These deficiencies were noted on the afternoon of 07/16/14.

(a) The facility was not provided with an NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 3 Essential Electrical System. Examples include but are not limited to:

(i) A single automatic transfer switch serves both NFPA 70 Article 700 loads (e.g., fire alarm, emergency lighting) and non-Article 700 loads that are not essential to safety to human life (e.g., 4th Floor Infusion Center, 3rd Floor Wound Care refrigerator outlet).

(ii) Article 700 - Emergency System wiring was not completely independent of all other wiring and equipment in that emergency power panel board "EPPL1" served both Article 700 Emergency System loads (e.g., Fire Alarm Control Panel) and non-Article 700 Emergency System loads (e.g., refrigerator receptacle).

42 CFR 482.41(b), 1999 NFPA 99: 13-3.3.2, 3-6, 1999 NFPA 70: Article 700, 1999 NFPA 110
10NYCRR, 405.24(b), 711.2(a)(1)

(b) The facility was not provided with two (2) exit stairwells remotely located from each other. This was noted for Stairs 1 & 2 with exit doors approximately thirty-four (34) feet in separation.

42 CFR 482.41(b), 2000 NFPA 101: 7.5.1.3
10NYCRR, 405.24(b), 711.2(a)(1)

(c) The facility failed to ensure that exit stairwells discharged to the exterior of the building or met the exceptions specified in 7.7.2. One (1) of two (2) exit stairwells discharged to the 1st Floor Elevator Lobby. The 1st Floor level of exit discharge was not protected by a sprinkler system.

42 CFR 482.41(b), 2000 NFPA 101: 7.7.2
10NYCRR, 405.24(b), 711.2(a)(1)

(d) The facility failed to ensure a minimum Type II (111) construction type as indicated by a Fire Safety Evaluation System (FSES) dated 03/22/07. Steel structural members (joists, beams) in the 2nd Floor core and in the 1st Floor suites were not provided with fire proofing. The lack of adequate fire proofing on steel structural members would mean that this building would be considered to be a Type II (000) unprotected, non-combustible structure.

42 CFR 482.41(b), 2000 NFPA 101: Chapter 39, 1999 NFPA 220
10NYCRR, 405.24(b), 711.2(a)(1)

(e) The facility failed to ensure that insulated pipes not serving the stairs, did not penetrate through the stair enclosures. This was noted on the 4th Floor landing of Stairs 1 & 2

42 CFR 482.41(b), 2000 NFPA 101: 7.1.3.2.1
10NYCRR, 405.24(b), 711.2(a)(1)

(f) The facility failed to ensure that fire extinguishers mounted in cabinets shall be marked conspicuously in that approximately four (4) fire extinguishers mounted in cabinets in the corridors in the 4th Floor Pediatric Cancer Center Suite lacked signage.

42 CFR 482.41(b), 1998 NFPA 10: 1-6.6, 1-6.12
10NYCRR, 405.24(b), 711.2(a)(1)

(g) The facility was noted with approximately seven (7) Alcohol Based Hand Rub (ABHR) dispensers installed in a corridor over carpet in a building that was not fully sprinklered. This was noted in the vicinity of the Exam Rooms in the 3rd Floor PAT Suite and in the Reception Area of the 3rd Floor Wound Care Suite.

42 CFR 482.41(b), 2000 NFPA 30
10NYCRR, 405.24(b), 711.2(a)(1)

(h) The facility failed to ensure that the basement Fire Pump Room was separated from all other areas of the building by two (2) hour fire-rated construction in that an unsealed cable penetration and a conduit with an unsealed wire penetration were noted lacking a UL listed fire stopping material.

42 CFR 482.41(b), 1998 NFPA 25: 5-1.4, 1999 NFPA 20: 2-7.1.1
10NYCRR, 405.24(b), 711.2(a)(1)

As per concurrent interviews with the Vice President of Engineering & Facilities, he stated that all of the above conditions will be addressed immediately.


7. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Ambulatory Surgery Center located at 777 Zeckendorf Boulevard, Garden City, New York. These deficiencies were noted on the afternoon of 07/16/14.

(a) The facility failed to ensure that the smoke barrier door in the vicinity of the sterile corridor was provided with a vision panel.

42 CFR 482.41(b), 2000 NFPA 101: 21.3.7.6
10NYCRR, 405.24(b), 711.2(a)(1)

(b) The facility failed to ensure that the smoke barrier shall have a fire resistance rating of not less than one (1) hour in that unsealed penetrations lacking a UL listed fire stopping material were noted in the smoke barrier. Examples are:

(i) An unsealed single wire penetration above the smoke barrier door to the restricted area.

(ii) A partially sealed penetration around Bx conduit and wires over the smoke barrier door to the sterile corridor.

42 CFR 482.41(b), 2000 NFPA 101: 21.3.7.3, 8.3
10NYCRR, 405.24(b), 711.2(a)(1)

(c) The facility failed to ensure that sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe in that a bundle of Bx cables was noted to be tied to the sprinkler pipe in the Manifold Room.

42 CFR 482.41(b), 1999 NFPA 13: 2-2.2
10NYCRR, 405.24(b), 711.2(a)(1)

As per concurrent interviews with the Vice President of Engineering & Facilities, he stated that all of the above conditions will be addressed immediately.
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.
1. Based on observations and record (i.e., panel board schedule) reviews and staff interviews during the Federal Allegation Survey, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate critical branch, life safety ranch, and equipment systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this facility.

Findings:

(a) On 07/14/14 at 10:39AM, review of the emergency power panel directory for panel "LS6A" on the 6th Floor of the Hoag Pavilion revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit lights) and Emergency System-Critical Branch loads (e.g., Nurse call system and PEVCO pneumatic tube system controls). As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

(b) On 07/14/14 at 11:33AM, review of the emergency power panel directory for panel "LSLPH3" on the 3rd Floor of the Hoag Pavilion revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., medical gas alarms, fire/smoke dampers, elevator cab lights, elevator communication systems), Emergency System-Critical Branch loads (e.g., Nurse call system for OR 10 and Cath Lab), and Equipment System loads (e.g., heat trace). As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will notify facility Administration concerning this condition.

(c) On 07/14/14 at 12:20PM, review of the emergency power panel directory for panel "LS2A" on the 2nd Floor of the Hoag Pavilion revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit lights) and Emergency System-Critical Branch loads (e.g., Nurse call system).

(d) On 07/14/14 at 2:30PM, review of the emergency power panel directory for panel "ELP4Y" on the 4th Floor of the Main Building revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit lights) and Emergency System-Critical Branch loads (e.g., corridor receptacles, Steris machine).

(e) On 07/15/14 at 9:33AM, review of the emergency power panel directory for panel "ELP2Y1" on the 2nd Floor of the Main Building revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., medical gas alarm, elevator cab lights) and Emergency System-Critical Branch loads (e.g., EP Lab receptacles, EP Lab task lighting).

(f) On 07/15/14 at 10:05AM, review of the emergency power panel directory for panel "LP2CR" on the 2nd Floor of the Main Building revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., medical gas alarm) and Emergency System-Critical Branch loads (e.g., Special Procedures Room receptacles).

(g) On 07/15/14 at 10:30AM, review of the emergency power panel directory for panel "ELPINA" Section1 and Section 2 on the 1st Floor of the Main Building revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, medical gas alarm) and Emergency System-Critical Branch loads (e.g., Endo Room 115 and 116 receptacles).

(h) On 07/15/14 at 12:23PM, review of the emergency power panel directory for panel "LPEB" on the Ambulatory Surgery Unit Building Lower Level Electrical Room revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., generator annunciator alarm panel, stairway lights, fire alarm system, medical gas alarm) and Emergency System-Critical Branch loads (e.g., Pxyis machine).

(i) On 07/15/14 at 12:33PM, observations revealed that wiring from Emergency System-Critical Branch panel "CREB" was improperly run through a hole in a metal raceway separation barrier into a raceway containing wiring from Emergency System-Life Safety Branch panel "LPEB" in the Ambulatory Surgery Unit Building Lower Level Electrical Room. Wiring from the Emergency System-Critical Branch is required to be kept separate from the Emergency System-Life Safety Branch.

(j) On 07/15/14 at 3:11PM, review of the emergency power panel directory for panel "LSLPNB5" on the North Pavilion Building 5th Floor Electrical Room revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, medical gas alarm, elevator pre-action sprinkler system) and Emergency System-Critical Branch loads (e.g., Nurse call system, receptacles).

(k) On 07/16/14 at 9:45AM, observations revealed that wiring from a fire alarm power extender panel (a device that is supposed to be connected to the Emergency System-Life Safety Branch) was improperly run through a hole in a metal raceway separation barrier into Emergency System-Critical Branch electrical panels "LP2A" and "LP2B" in a 2nd Floor Potter Pavilion Electrical Equipment Room (near Room 270). Wiring from the Emergency System-Critical Branch is required to be kept separate from the Emergency System-Life Safety Branch.

(l) On 07/16/14 at 11:40AM, observations revealed that wiring from Emergency System-Critical Branch panel "CRLP12" was improperly run into a raceway containing wiring from Emergency System-Life Safety Branch panel "LSLP11" in a New Life Center building 1st Floor Electrical Room. Wiring from the Emergency System-Critical Branch is required to be kept separate from the Emergency System-Life Safety Branch.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24(b), 711.2(a)(1), 711.2(a)(20)
.

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1. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair or that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings were effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings:

(a) On 07/14/14 at 11:11AM, a cracked duplex receptacle was noted in the vicinity of ICU cubicle 1 in the 3rd Floor ICU Suite in the Hoag Pavilion.

(b) On 07/14/14 at 2:40PM, an electrical conduit body was noted to be open on one (1) side (e.g., was missing a cover plate) in an Electrical Room on the 3rd Floor of Hoag Pavilion Infill Area.

(c) On 07/14/14 at 11:11AM, a cracked duplex receptacle was noted in the 4th Floor Main Building PACU.

(d) On 07/15/14 at 9:01AM, an unprotected opening due a missing circuit blank was noted in electrical panel "CRDPB" located in a 3rd Floor Main Building Electrical Room.

(e) On 07/15/14 at 12:17PM, a wall-mounted electrical junction box in Main Building Lower Level Mechanical Room 35 was noted be missing a cover plate on one (1) side of the box.
Corrected onsite.

As per concurrent interviews with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12

10NYCRR, 405.24(b), 711.2(a)(1)


2. Based on observations and staff interviews, the facility failed to ensure that flexible cords and cables are not used as a substitute for the fixed wiring of a structure.

Findings:

(a) On 07/15/14 at 9:15AM in the Laboratory Unit on the 3rd Floor of the Main Building, several extension cords and relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). In addition, the electrical cable at both the male and female ends of an extension cord in use in the Laboratory were noted to be frayed/in disrepair. The facility's Vice President of Engineering & Facilities took immediate corrective action by removing the "daisy chained" relocatable power taps and extension cords. He said that he would try to have additional duplex electrical receptacles installed in this area so that electrically powered equipment can be properly connected directly to fixed wiring.

(b) On 07/15/14 at 9:47AM, an extension cord with what appear to be a fifty (50) amp twist-lock receptacle was found to have been improperly wired directly from emergency power panel "LP2LSC" in a 2 Main Electrical Closet (near the Cardiology Clerical Supply Storage Closet). As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have this extension cord removed immediately.
Corrected onsite.

(c) On 07/15/14 at 12:40PM in the Main Building Lower Level Robotic Pharmacy Area, several relocatable power taps (e.g., "surge protectors") were found to be improperly attached in sequence to each other (i.e., "daisy chained"). As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have this condition corrected immediately.
Corrected onsite.

(d) On 07/16/14 at 12:24PM in the Potter Pavilion Lower Level Main Information Technology Server Room, a couple of extension cords were found to be improperly attached in sequence to each other (i.e., "daisy chained"). As per concurrent interview with the facility's Vice President of Engineering & Facilities, he will have this condition corrected immediately.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

10NYCRR, 405.24(b), 711.2(a)(1)


3. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that electrically powered biomedical equipment was used in accordance with its manufacturer's instructions.

Findings:

On 07/16/14 at 10:19AM, an electrically powered vital signs monitor that was required to be connected to a listed Hospital Grade receptacle that was improperly connected to a non-Hospital Grade duplex receptacle in the Winthrop Pavilion 2nd Floor Non-Invasive Procedure Patient Prep Room. As per concurrent interview with the facility's Vice President of Engineering & Facilities, corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)

10NYCRR, 405.24(b), 711.2(a)(1)