New Gouverneur Hospital SNF
April 5, 2018 Certification/complaint Survey

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 27, 2018

Citation Details

2009 NFPA 17A: 7.2 Owner's Inspection. 7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 7.2.2 At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) Tamper indicators and seals are intact. (4) The maintenance tag of certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge (s), if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. Based on observation and staff interview, the facility failed to ensure that at a minimum, quick checks were being performed on the extinguishing equipment in the kitchen within the facility. The finding is: On 4/16/2018 between the hours of 9am and 3pm during the recertification survey, the following was observed: The pull station for the Ansul System in the Kitchen was noted to contain an inspection tag. The tag contained the semi-annual inspection dated Oct (YEAR). The reverse side of the tag contained two columns for the monthly quick check. The columns were not filled out. In an interview on 4/16/2018 at approximately 12:15pm with the Director of Safety, Security and Emergency Management, he stated the facility performs a semi- annual inspection, but not a monthly inspection. 2011 NFPA 96 2009 NFPA 17A 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 18, 2018

K324
I. Action Taken to Correct Deficiency
The pull system for the Ansul System was inspected and the monthly quick check portion of the tag completed. Completion Date: 4/19/18

II. Identification of other similar issues
No similar systems exist at the facility.

III. Systems and measures to prevent recurrence
Monthly quick checks of the Ansul system have been incorporated into the monthly fire extinguisher inspection rounds performed by the fire safety team. Completion Date: 4/19/18

IV. Monitoring compliance
Results of the fire extinguisher inspection rounds will be reported to the Environment of Care committee for the next six months. Completion Date: 5/17/18

K307 NFPA 101:CORRIDORS - CONSTRUCTION OF WALLS

REGULATION: Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 27, 2018

Citation Details

2012 NFPA 101: 19.3.6.2 Corridors are separated from use areas by walls constructed with at least ½-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. 2012 NFPA 101: 19.3.6.2.2* Corridor walls shall have a minimum 1?2-hour fire resistance rating. 2012 NFPA 101: 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke. Based on observation and staff interview, it was determined that the facility did not ensure that corridor walls were smoke resistant in accordance with NFPA 101, 2012 edition. This was noted on 1 of 9 floors within the facility. The finding is: On 4/17/2018 between the hours of 9am and 3pm during the recertification survey, the following was observed: The electrical closet located on the 6th floor contained 2 conduit penetrations. The annular space around the conduit penetrations were unsealed. In an interview on 4/17/2018 at approximately 12:00pm, the Director of Safety, Security and Emergency Management stated that recently, work was done within that room. He further stated he could add firestopping around the pipes. 2012 NFPA 101: 19.3.6.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 18, 2018

K362
I. Action Taken to Correct Deficiency
The annular space around the conduit penetrations in the 6th floor electrical closet were sealed with intumescent fire-stopping caulk. Completion Date: 4/19/18

II. Identification of other similar issues
All other areas where electrical work was recently undertaken have been checked for penetrations and none were noted. Completion Date: 4/19/18

III. Systems and measures to prevent recurrence
Environmental rounds are conducted weekly and areas will be monitored for penetrations and adjusted/repaired as necessary.

A work-order system is in place to allow for reporting and follow up of engineering and maintenance issues identified during environmental rounds. Staff were re-educated on the use of this system. Completion Date: 6/8/18
IV. Monitoring compliance
The results of environmental rounds findings as it relates to the review of penetrations will be reported to the Environment of Care committee for a period of six months. Completion Date: 5/15/18

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 27, 2018

Citation Details

19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. Based on observation and staff interview, the facility failed to ensure that hazardous areas contained a self- closing door. This occurred in the basement of the facility. The findings are: On 4/16/2018 between the hours of 9am and 3pm during the recertification survey, the following was observed: Rooms used for storage that were greater than 50 ft2 either lacked a self-closing door or the self - closing device did not function as designed. Locations include, but are not limited to: 1) The door to the storage area/ loading dock near the trash compactor 2) The old switch gear room 3) Electrical Office/ Shop In an interview on 4/16/2018 at 12:10pm, the Director of Safety, Security and Emergency Management stated he can adjust the self-closing device on the door.

Plan of Correction: ApprovedMay 18, 2018

K321
I. Action Taken to Correct Deficiency
The door closer to the storage area/loading dock near the trash compactor was adjusted/repaired. Completion Date: 4/19/2018
The door closer for the old switch gear room was adjusted/repaired. Completion Date: 4/19/2018
The door closer for the electrician?s shop was adjusted/repaired. Completion Date: 4/19/2018
II. Identification of other similar issues
All other doors to hazardous areas were inspected and found to be self-closing and in good condition. Completion Date: 4/19/2018

III. Systems and measures to prevent recurrence
Environmental rounds are conducted weekly and the doors to hazardous areas will be monitored and adjusted/repaired as necessary.

In addition a work-order system is in place to allow for reporting and follow up of engineering and maintenance issues identified during environmental rounds. Staff were re-educated on the use of this system. Completion Date: 6/8/18

IV. Monitoring compliance
The results of environmental rounds findings as it relates to the review of self-closing doors to hazardous areas will be reported to the Environment of Care committee for a period of six months. Completion Date: 5/17/18