Ozanam Hall of Queens Nursing Home Inc
September 16, 2016 Certification Survey

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: The nursing home/hospice with no life support equipment shall have an alternate source of power separate and independent from the normal source that will be effective for minimum of 1 1/2 hour after loss of the normal source 3-6. (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 16, 2016
Corrected date: November 15, 2016

Citation Details

NFPA 99, Standard for Health Care Facilities section 16-3.3.2 requires that free standing nursing homes have a Type 2 Essential Electrical System unless they meet all of the requirements of the listed exception. The exception to 16-3.3.2 allows a Type 3 Essential Electrical Systems provided that the facility has specific written admitting and discharge policies and procedures that preclude the provision of care for any patient or resident who needs to be sustained on electrical life support, offers no surgical treatment requiring general anesthesia, and provides an automatic battery-powered system or equipment that will be effective at least 1.5-hours and otherwise in accordance with NFPA 101, Life Safety Code, and NFPA 70, National Electrical Code, and that will be capable of supplying light of at least 1-foot candle to exit lights, exit corridors, stairways, nursing stations, medication preparation areas, boiler rooms, and communications areas. This system must also supply power to operate all alarms systems. In addition, NFPA 99 section 3-6.2.2.3 requires the design, arrangement, and installation of wiring for the Type 3 Essential Electrical System is in compliance with the requirements of NFPA 70, National Electrical Code. Article 700-6 (d) of NFPA 70 requires that a separate automatic transfer switch be provided for NFPA 70 Article 700 Emergency System loads (e.g., fire alarm, emergency lighting) only and that separate automatic transfer switches would be needed to serve Non- Article 700 loads (e.g., loads that are not essential to safety to human life). Based on observation, document review (i.e., posted electrical panel schedules) and staff interview, the nursing home was not provided with at least a Type 3 Essential Electrical System (EES) installed in accordance with NFPA 99 - Health Care facilities, NFPA 70 - National Electrical Code, and NFPA 110 - Emergency Power Systems. This was noted on seven of ten resident-use floors. The findings are: On 9/13/16 between 9:00am- 2:00pm during the recertification survey, wiring for NFPA 70 Article 700 - Emergency Systems loads was not entirely independent of all other wiring and equipment. The wiring shared panelboards with Article 701 - Legally Required Standby Systems and Article 702- Optional Standby System loads. The following was noted: 1) Emergency panelboards located in the electrical rooms on the B wing on the 6th, 7th and 9th floors, served both the Article 700 Emergency System (corridor lights), and Article 701/702 loads (TV cabinet). 2) Emergency panelboards located in the electrical rooms on the A wing on the 3rd, 4th, 6th, 7th, 8th, 9th, and 10th floors, served both the Article 700 Emergency System (nurse call system), and Article 701/702 loads (time clock). In an interview on 9/13/16 at approximately 11:10am, the Director of Engineering stated that he will have the circuits moved. 10NYCRR 711.2(a)(1) 1999 NFPA 99: 13-3.3.2, 3-6.2.2.3 1999 NFPA 70: Article 700, Article 701, Article 702 1999 NFPA 110: 5-3.1

Plan of Correction: ApprovedNovember 28, 2016

Element #1: The Director of Engineering was made aware of these findings on 9/13/16 during an interview during the Re-Certification survey.
Date of Completion; 9/13/16
Element # 2.1: The Director of Engineering evaluated the Power Panels on all floors on Wings ?A? & ?B?.
Date of Completion: 10/21/16
Element # 2.2: The Director of Engineering had found that on the Power Panels on the ?A? wing had a circuit labeled for Time Clocks. The circuit was installed for the old Time Clock system and is no longer being used. The New Time Clock system uses POE power from the Network Switch.
Date of Completion: 10/21/16
Element 2.3: The Director of Engineering has found during his evaluation that the Power Panels on the ?B? Wings has circuits labeled for T.V. Cabinet which does not meet the Article 700 Emergency System Load Requirement.
Date of Completion: 10/21/16
Element 3.1: The Director of Engineering will be changing the designation of the Circuit Breaker from Time Clock to Corridor Outlet.
Date of Completion: 10/28/16
Element # 3.2: The Director of Engineering is in the process of securing bids from Electrical Contractors to remove the T.V. Cabinet circuit from the ?B? wing Emergency Power Panel and having it installed in the Normal Power Panel.
Date of Completion: 11/15/16
Element #4: Quality Assurance activity will not be applicable for K-146.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit". 7.10, 18.2.10.1, 19.2.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 16, 2016
Corrected date: November 15, 2016

Citation Details

2000 NFPA 101: 7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. Based on observation and staff interview, exits were not marked by signs readily visible in that: 1) signs were not provided in exit discharge corridors on resident sleeping floors; and 2) an exit sign was not lit within Stair A on the 1st floor landing. This was noted on four of ten resident-use floors. The findings are: On 9/13/16 & 9/14/16 between 9:00am- 2:00pm during the recertification survey, exits were not marked by signs readily visible. Examples are: 1) Exit signs were not provided in exit discharge corridors. Examples are: a. Above Stair B on the 10th floor b. In the vicinity of the nursing station on the 9th floor c. In the vicinity of the nursing station on the 2nd floor 2) An exit sign was not lit within Stair A on the 1st floor landing. In an interview on 9/13/16 at approximately 12:15pm, the Director of Engineering stated that the exit signs would be addressed. 10NYCRR 711.2(a)(1) 2000 NFPA 101: 7.10.1.2

Plan of Correction: ApprovedNovember 28, 2016

Element #1: The Director of Engineering was made aware of these findings during the Re- Certification survey.
Date of Completion: 9/14/16
Element #2: The Director of Engineering started an investigation as to why the exit signs were not visible.
Date of Completion: 9/14/16
Element #3: The Director of Engineering found that the Foil sheet between the plastic EXIT signs was missing which made the signs not readily visible. The Director of Engineering designated a Maintenance employee to install Foil sheets in the Exit signs correcting the issue of visibility.
Date of Completion: 9/16/16
Element #4: The Director of Engineering/Designee will conduct Quality Assurance activity monthly to ensure proper visibility and illumination until 100% compliance is achieved. Frequency of audit will be reviewed in 3 months.
Date of Completion: 11/15/16

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 16, 2016
Corrected date: November 15, 2016

Citation Details

19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1- hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. The doors shall be self-closing or automatic closing. 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. Soiled linen rooms 6. Trash collection rooms 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. Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48in. (122 cm) above the bottom of the door. Based on observation and staff interview, the facility failed to ensure that hazardous areas were protected with self- closing or automatic closing doors. This was observed on 3 of 13 floors including the concourse (basement) level. The findings are: On 9/13/2016 and 9/14/2016 between the hours of 9am and 1pm during the recertification survey, the following was observed: Rooms considered to be hazardous areas due to the combustible load stored within the room were not equipped with a self-closing or automatic closing device. The locations include but are not limited to: 1) The Rehab Equipment storage room on the 2nd floor 2) The gift shop and the Medicaid office on the 1st floor 3) The storage room within the Personnel room on the concourse level. In an interview at approximately 10:30am with the infection control nurse, she stated she would inform maintenance of the issue and install the closer on the door. 10NYCRR 711.2(a)(1) 2000NFPA101:19

Plan of Correction: ApprovedNovember 28, 2016

Element #1: The Director of Engineering was made aware of these findings during the Re- Certification survey.
Date of Completion: 9/14/16
Element # 2.1: The Director of Engineering determined that the doors to the Rehab Equipment Storage room, 1st floor Medicaid Office, and Storage room within Personnel office on the Concourse were in need of Self-Closers.
Date of Completion: 9/14/16
Element # 2.2: The Director of Engineering investigated the Gift shop Door closer issue.
Date of Completion: 9/14/16
Element # 3.1: The Director of Engineering purchased and had installed Self-Closing Device on the Rehab Equipment Storage, 1st floor Medicaid office and the Concourse Personnel Storage Room doors.
Date of Completion: 9/15/16
Element # 3.2: After the Director of Engineering?s investigation it was found that the Gift Shop door already had an Automatic Closer connected to the Fire Alarm System and the door will automatically close upon Fire Alarm Activation.
Date of Completion: 9/16/16
Element # 4: The Director of Engineering/Designee will conduct Quality Assurance activity related to Door Self-Closure Devices to ensure proper functioning every month until 100% compliance is achieved. Frequency of auditing will be reviewed at that time.
Date of Completion: 11/15/16