New Gouverneur Hospital SNF
March 16, 2017 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2017
Corrected date: August 14, 2017

Citation Details

2010 NFPA 99: 6.5.2.2 Specific Requirements. 6.5.2.2.1* General. 6.5.2.2.1.1 The number of transfer switches to be used shall be based upon reliability, design, and load considerations. 6.5.2.2.1.2 Each branch of the essential electrical system shall have one or more transfer switches. 6.5.2.2.1.3 One transfer switch shall be permitted to serve one or more branches in a facility with a continuous load on the switch of 150 kVA (120 kW) or less. 2010 NFPA 99: 6.5.2.2.2 Life Safety Branch. 6.5.2.2.2.1 The life safety and critical branches shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code (2) Exit signs and exit directional signs in accordance with 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 5 (4)*Communications systems, where used for issuing instructions during emergency conditions (5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles (6) Task illumination and select receptacles at the generator set location (7) Elevator cab lighting, control, communications, and signal systems 6.5.2.2.2.2 No functions, other than those listed in 6.5.2.2.2.1(1) through (7), shall be connected to the life safety. 2010 NFPA 99: 6.5.2.2.3 Equipment Branch. 6.5.2.2.3.1 General. (A) The equipment branch shall be installed and connected to the alternate power source such that equipment listed in 6.5.2.2.3.2 is automatically restored to operation at appropriate time-lag intervals following the restoration of the life safety and equipment branches to operation. (B) The equipment branch arrangement shall also provide for the additional connection of equipment listed in 6.5.2.2.3.3. 6.5.2.2.3.2 AC Equipment for Nondelayed-Automatic Connection. Generator accessories including, but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation shall be arranged for automatic connection to the alternate power source. 6.5.2.2.3.3 Delayed-Automatic Connections to Equipment Branch. The following equipment shall be permitted to be connected to the equipment branch and shall be arranged for delayed-automatic connection to the alternate power source: (1) Task illumination and select receptacles in the following: (a) Patient care rooms (b) Medication preparation areas (c) Pharmacy dispensing areas (d) Nurses' stations (unless adequately lighted by corridor luminaires) (2) Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms (3) Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms (4) Smoke control and stair pressurization systems (5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood 6.5.2.2.3.4* Delayed-Automatic or Manual Connections to Equipment Branch. The equipment in 6.5.2.2.3.4(A) and 6.5.2.2.3.4(B) shall be permitted to be connected to the equipment branch and shall be arranged for either delayed-automatic or manual connection to the alternate power source. (A) Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: (1)*The outside design temperature is higher than ?6.7C (+20F). (2) The outside design temperature is lower than ?6.7C (+20F) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated. (3) The facility is served by a dual source of normal power. See A.6.4.1.1.1 for more information. (B)* Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throwover facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (C) Optional Connections to the Equipment Branch. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the equipment branch. (D) Multiple Systems. Where one switch serves multiple systems as permitted in 6.5.2.2, transfer for all loads shall be nondelayed automatic. 2011 NFPA 70: Article 517.41 Essential Electrical Systems. (D) Separation from Other Circuits. The life safety branch shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with other wiring except as follows: (1) In transfer switches (2) In exit or emergency luminaires supplied from two sources (3) In a common junction box attached to exit or emergency luminaires supplied from two sources The wiring of the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the life safety branch. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not provided with an NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 2 Essential Electrical System in that the Life Safety Branch wiring was not separated from the Equipment Branch wiring. This was noted on three of seven skilled nursing floors. The findings are: On 3/13/17 between 9:30am- 12:30pm during the re-certification survey, emergency power panels were noted to contain wiring from both the Life Safety Branch and Equipment Branch. Examples are: 1) Emergency power panel LPLS-9B located in the 9th floor electrical room contained loads from both the Life Safety Branch (#1 & 3 8th floor lighting, #5 & 7 9th floor lighting) and the Equipment Branch (#9 & 11 Nurse Call Cabinet) 2) Emergency power panel LPLS-7B located in the 7th floor electrical room contained loads from both the Life Safety Branch (#1 & 3 lighting 7th floor (Sec. A&B)) and the Equipment Branch (#5 & 7 Nurse Call Cabinet) 3) Emergency power panel LPCE-7B located in the 7th floor electrical room contained loads from both the Life Safety Branch (#12 Fire Smoke Dampers) and the Equipment Branch (#1 - 7 Receptacles) 4) Emergency power panel LPCE-5A located in the 5th floor electrical room contained loads from both the Life Safety Branch (#1 & 3 Fire Smoke Dampers) and the Equipment Branch (#3 & 4 Air Handling Unit) In an interview on 3/13/17 at approximately 11:30am, the Director of Engineering stated that he will have the circuits moved. NFPA 99-2010 Standard for Health Care Facilities: 6.5 NFPA 70-2011 National Electrical Code: Article 517.41 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 23, 2017

The Emergency Power Panels which were noted to contain wiring from both the Life Safety Branch and Equipment Branch were reviewed with the original Architect/Engineer of Record on 4/21/17.
The Engineer of Record will oversee that LPLS-9B located in the 9th floor electrical room and LPLS-7B located in the 7th Floor electrical room each containing the Nurse Call Cabinet and the Life Safety Branch will be separated. The work will be completed by end of May, (YEAR).
The Emergency Power Panels LPCE-7B and LPCE-5A were constructed under 2005 NFPA standards. The separation of the Life Safety Branch and the Equipment branch will be evaluated by a consultant for the corrective actions to be taken.
We have FDNY certified Fire Safety Directors who maintain ongoing surveillance throughout the facility 24 hours a day, 7 days per week and the Director of Safety will direct them to have enhanced focus on these areas until the work is completed.
The work will be overseen by the Senior Associate Executive Director.
The facility is applying for a Time Limited Waiver to address these findings.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2017
Corrected date: August 14, 2017

Citation Details

2011 NFPA 25: INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS. Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance Item Frequency Reference Inspection. Check Valves Interior 5 years 13.4.2.1 This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not provide updated information of the required five year maintenance of the sprinkler system check valve. The findings are: During the Life Safety Code survey conducted on 03/15/17 approximately 11:22am, during an inspection of the fire pump room, it could not be determined that the check valve associated with the building's automatic sprinkler system was inspected/maintained at the required five year interval. The facility did not provide updated information for the required check valve five year maintenance. Additionally, the facility did not provide documentation for the sprinkler system installation. In an interview on the same day at approximately 2:10pm, the Executive Administrator stated that the required maintenance of the sprinkler system check valve would be completed as determined. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedApril 27, 2017

On (MONTH) 20, (YEAR), an internal check valve inspection on the fire pump by-pass check valve, located in the Fire Pump Room, was conducted by Complete Fire Safety. The check valve was found to be operating correctly, moving freely, and to be in good condition. All gauges were removed and replaced with new calibrated gauges.
The next year five-year review will be performed in accordance to schedule overseen by the Director of Engineering.
This report will be presented to the Environment of Care Committee on (MONTH) 18, (YEAR).

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2017
Corrected date: August 14, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the fire resistive rating for glass panels incorporated in the smoke barriers could not be determined on 6 of 6 resident sleeping floors. The findings are: During the Life Safety Code survey conducted on 03/13/17 and on 03/15/17 between 9:00am and 2:30pm, the required minimum ½ hour fire resistive rating of the glass panels that are incorporated in the smoke barriers could not be determined. This was noted on the 13th, 11th, 9th, 8th, 7th, and 6th resident sleeping floors. Inspections of the glass panels indicated that they were tempered glass. In an interview on 03/13/17 at approximately 11:00am, the Executive Administrator stated that the glass panels were approved for use in the smoke barriers, and that the fire resistive rating would be provided if available. The facility did not provide documentation of the fire resistive rating for the glass panels at the conclusion of the survey. 2012 NFPA 101: 19.3.7.3, 8.6.7.1(1) 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 23, 2017

On (MONTH) 9, (YEAR) the glass panels that are incorporated into the smoke barriers will be reviewed by an Engineering Consultant and representatives from the Dormitory Authority of the State of New York for confirmation of fire rating or for replacement. The areas for review will include floors 13, 11, 9, 8, 7 and 6. We will then check NFPA Life Safety Code to determine the corrective action for these conditions.
Once identified we will obtain pricing from an outside contractor and award the work to be completed.
We have FDNY certified Fire Safety Directors who maintain ongoing surveillance throughout the facility 24 hours a day, 7 days per week and the Director of Safety will direct them to have enhanced focus on these areas until the work is completed.
The work will be overseen by the Senior Associate Executive Director.
The facility is applying for a Time Limited Waiver to address these findings.