Dumont Center for Rehabilitation and Nursing Care

Physical Plant Violation - State Only

NYCRR 710.1(c)(5) Proposals requiring a prior review limited to architectural and engineering matters.
(i)(a) Proposals where total project cost does not exceed $3,000,000, and for which a certificate of need is not otherwise required under this Part, shall be subject to review under Article 28 of the Public Health Law limited to a determination of whether the proposal is consistent with applicable statutes, codes, rules and regulations relating to the structural, architectural, engineering, environmental, safety and sanitary requirement of licensed medical facilities where the proposal relates to the acquisition, relocation, installation or modification of:

(4) heating, ventilating, air conditioning, plumbing, electrical, water supply, fixed dietary, solid waste and/or sewage disposal, and fire protection systems, other than routine maintenance and repairs or routine purchases affecting such systems.

(ii) Requests for approval of proposals described in this paragraph shall be made directly to the Bureau of Architectural and Engineering Review at the central office of the department in Albany. The applicant shall submit such information and documentation as is required to determine the acceptability of the proposal. If the Bureau of Architectural and Engineering Review determines that a proposal complies with all pertinent statutory and regulatory requirements, the director of such bureau shall notify the applicant, in writing, that the proposal is acceptable. If the Bureau of Architectural and Engineering Review determines that the proposal is not acceptable, the director of such bureau shall notify the applicant, in writing, of such determination the basis thereof. if the applicant has not submitted an acceptable proposal within 30 days of such determination, then the proposal shall be deemed an application subject to full review pursuant to section 2802 of the Public Health Law and this Part and shall be submitted to the State Hospital Review and Planning Council and the local health systems agency, with a staff recommendation of disapproval, for their recommendation.

710.7
Approval to start construction. (a) The applicant may seek approval to start construction of the project, or one or more phases thereof, upon the filing with the department completed contract documents consistent with all previous approvals.

(b) If documents are not completed, the applicant may request approval to start construction upon submission of a certification by the applicant, construction manager or contractor, and the architect that completed working drawings and specifications shall be submitted within a time period specified in the applicant's request, that such construction shall be undertaken at the applicant's risk and that approval is understood to be contingent upon submission of the completed documents as a no-cost change order.

(c) A request by the applicant pursuant to subdivision (a) or (b) of this section shall include an affidavit by the applicant's architect or engineer that the drawings:

(1) are consistent with schematic and design development drawings previously approved and, if not, the affidavit shall identify the changes and reasons for such changes; and

(2) are in compliance with the applicable provisions of this Title and all applicable local codes, statutes and regulations. In addition, the applicant shall submit an up-dated functional stack diagram consistent with section 710.2(b)(10)(i)(b) of this Part.

(d) When the submission under subdivision (a) or (b) of this section is deemed complete by the department, the applicant shall be advised in writing to commence construction pursuant to this Part.

This REQUIREMENT is not met as evidenced by:

Based on observations, interviews and documentation review, it was determined that the facility did not ensure that the physical environment was maintained in a safe manner in accordance with State requirements in that: 1.) previously approved cosmetic renovations had surpassed the scope of the approved narrative and safety plan; 2.) sprinkler system replacement and exterior facade repairs were taking place without the required prior review and approval by the Bureau of Architectural and Engineering Facility Planning (BAEFP) and without an acceptable safety plan; and 3.) work was not being completed in an orderly, workmanlike manner.
This was noted on one of three resident floors (1st floor) and the exterior of the building.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint No. 93191

Findings are:

A site visit was conducted on 10/26/10 subsequent to a complaint regarding renovation work taking place on the 1st floor of the facility. On 10/14/10, the regional office approved a narrative and corresponding safety plan for cosmetic renovations to take place on the 1st floor resident units only. The renovations were to include installing new wallpaper, flooring, and ceiling tiles.

The onsite investigation conducted between 2:30 PM and 4:45 PM revealed the following:

1. Cosmetic renovations had gone beyond the scope of what had originally been approved by the regional office. A tour of the lobby area revealed that extensive renovations of the multipurpose room were under way. In particular, two new corridor exit doors were going to be installed where none had existed before. Additionally, as per interview with the owner the same day, the stained glass ceiling in the entry way to the multipurpose room had been removed by the previous owners and a new ceiling was in the process of being constructed. These renovations had not been included in the original narrative and safety plan that had been reviewed and accepted by this office on 10/14/10.

2.) Sprinkler system replacement and exterior facade repairs were taking place without the required DOH review and approval. The following was observed:
A. A section of sprinkler pipe measuring approximately 2 feet in length had been cut and was hanging vertically from the corridor ceiling outside of resident room #116. One resident was observed to be sitting in the corridor near this pipe. In an interview at the time, the Administrator stated that the old sprinkler system had been removed beginning on 9/20/10. He further stated that a limited review application had not been submitted to the BAEFP. A tour of all 4 resident floors confirmed that the sprinkler replacement had taken place on the 1st floor only. Newly installed concealed pendent sprinkler heads and numerous penetrations left by the removal of the old sprinkler pipes were noted in resident rooms and the corridors.
B. A tour of the outside of the property revealed that scaffolding with netting had been installed along the entire north side of the building. Contractors were observed to be working on the facade at the time of this visit. In an interview at the time, the Administrator stated that an engineer had been consulted and had determined that the facade of the building required repairs. The facility's previous owners had done emergency facade work back in November of 2009 (with the knowledge of the regional office and an approved safety plan), with the understanding that if further repairs were needed, a limited review application would have to be filed.

In a separate interview the same day, the owner stated that he would check with the facility's consultants to verify whether limited review applications had been submitted for these projects.

3.) Work was not being completed in an orderly, workmanlike manner. The following examples of potentially unsafe work practices were observed on 10/26/10 between 2:30 - 4:30 PM:

- An approximately 2 foot section of sprinkler pipe was noted to be hanging vertically from the ceiling outside of resident room #116. One resident was observed to be sitting in the vicinity of this pipe and other residents were observed to be sitting throughout the corridors, especially near the Nurse's Station located opposite resident rooms #115 & 116. At the time of this observation, the Administrator instructed a contractor to remove the pipe. The contractor proceeded to plug a power tool into an outlet in the corridor to the left of room #116, and walked away. The Administrator further instructed this contractor not to leave tools and equipment unattended, and to unplug the tool until he was ready to use it.

- An extension cord that was plugged into an outlet near room # 113 extended across the corridor in front of the exit stairwell door and diagonally across the corridor to resident room # 111, creating a potential tripping hazard.

- There was no "Caution" signage posted in this area or any other area warning of the work taking place.

- Thin plastic sheeting installed as a dust barrier was torn (i.e. across room #114) and was not securely taped to the doorways, walls and floors in the vicinity of resident rooms # 103, 104, 105, etc. Torn sheeting may not provide an effective dust barrier.

- A tour of the lobby area revealed that the large multipurpose room opposite the reception and sitting areas were under renovation. A contractor was observed to walk out of the multipurpose room, leaving the double doors unlocked. Numerous residents and visitors were observed to be sitting in the area, and staff members were coming and going through the area as the shifts were changing. Power tools, including a table saw and a hand drill, as well as numerous other potentially hazardous tools and equipment, were left unattended for approximately 5 minutes, when the contractor returned.

In an interview at the time, the Administrator stated that he would talk to the contractors and their foreman. He further stated that maintenance department staff members make regular rounds of the work areas, and that all resident rooms are cleaned at the completion of work each day.

NYCRR 710.1, 710.7
10 NYCRR 415.29

2000 NFPA 101 Life Safety Code- Chapter 8.3.2 Continuity.- Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Chapter 8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1
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.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.

Based on observation and interview, the facility did not ensure that smoke barriers are constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3 in that multiple penetrations in the walls and ceiling tiles in resident rooms and the corridor. This was noted on one of four resident floors (1st floor).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint No. 93191

Findings are:

During a tour of the 1st floor nursing unit as part of a complaint investigation on 10/26/10 at 2:30 PM, the following was noted:
Multiple penetrations, measuring approximately 3 inches in diameter, were noted in corridor and resident room walls and ceilings. Examples include (not all inclusive): resident rooms # 118, 116, 115, 105, corridor outside room #105, corridor wall above mechanical room between rooms #103 and 104, ladies' bathroom opposite room #107.

In an interview at the time, the Administrator stated that contractors had removed the piping for the old sprinkler system, and that the work began on the south side of the unit on 9/20/10.
He further stated that the penetrations would be sealed immediately.

2000 NFPA 10 1 LSC: 8.3, 19.1.6.3, 19.1.6.4, 19.3.7.3, 19.3.7.5
NYCRR 415.29
10 NYCRR 711.2