Non-compliance with Fire Resistance Standards for Ventilation Ducts
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure that vertical ventilation duct penetrations passing through floors were protected in accordance with NFPA 101 and NFPA 90A standards. Specifically, the resident toilet exhaust ducts extending vertically from the first floor through the third floor were not enclosed with a minimum fire resistance rating of at least 1 hour. This deficiency was noted during the Life Safety Code survey conducted between March 5 and March 6, 2025. In an interview conducted on March 5, 2025, at 10:00 am, the facility's Engineering, Support, Administration, and Life Safety Personnel acknowledged that a project to address this issue was in the planning phase. This project included capital procurement, design, and permit application to install fire-rated dampers at the floor penetration of the vertical ventilation ducts. The facility had received an approved Time Limited Waiver from CMS to comply with the prescriptive code requirement, which is set to expire on October 10, 2026.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. III. The following measures and/or systemic changes will be implemented to ensure the deficient practice identified does not recur: Long Island State Veterans Home (LISVH) continues to utilize the Time Limited Waiver approved by CMS on (MONTH) 3, 2025, to address deficiency K-521. Listed below is the project update related to deficiency K-521: LISVH has secured an approved Veteran Affairs Construction Grant to fund the corrective actions required to address the K-521 HVAC bathroom exhaust deficiency. LISVH completed the bidding process to select a consultant to facilitate the design to correct the K-521 deficiency. The design was completed and sent to DOH for CON approval. The DOH approved the project CON on 1/14/2024. LISVH has generated the bid package and selected a construction contractor as well as the electrical vendor for the project. The electrical vendor contract has been awarded. LISVH purchasing department is preparing the construction contract for submittal to the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC). Upon receipt of approval from the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC), LISVH will finalize contract award and work to commence construction. Construction is estimated to begin (MONTH) 2025. LISVH Building Safety Features: - The building is fully sprinklered with quick action heads throughout the facility. - The building is protected by smoke detection and fire alarm pull stations. - Each floor is separated into multiple smoke compartments in the event of an emergency and relocation is required. LISVH additional fire safety protocols: - Staff are trained on Fire Safety upon hire; additional departmental Fire safety training will be conducted annually by the safety specialist and staff will undergo additional training on environment of care and safety, utilizing the facilities electronic education system. - Increase frequency of fire drills for all shifts. - Conduct training related to emergency management and evacuation drills. - Areas under construction will be assessed daily to ensure combustibles are removed and the area is neat and organized, prior to leaving the site each day and more frequently if necessary. - Fire protection system impairment policy shall be implemented in the event of a fire system impairment. - Require a Hot Work Permit. - In the event a partial or full evacuation is necessary, the facility in coordination with the fire department would initiate the necessary facility evacuation plan. This evacuation would occur with evacuating the Residents closest to the fire and then the floors above and below where the fire is located followed by the residents further away from the fire. The residents with higher acuity will be relocated within our facility or nearest hospital and then residents with lower acuity will be evacuated to alternate locations or facilities until the fire department is able to give further direction on the scope and severity of the fire. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will provide updates on the Bathroom Exhaust Project to the LISVH QAPI Committee. V. Responsibility: Director of Support Services