Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 31, 2024, at Allied Health Care Services Inc, Lynett Village., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 12601100
Component 01
421 Building
Based on a Medicaid Recertification Survey completed on January 31, 2024, at Allied Health Care Services Inc.-Lynett Village, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association ' s Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type V (000), unprotected, wood frame building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID# 12601100
Component 02
422 Building
Based on a Medicaid Recertification Survey completed on January 31, 2024, it was determined that Allied Health Care Services Inc.-Lynett Village, was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type V (000), unprotected, wood frame building, that is not sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - BUILDING 02 Component - 02
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5
Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered
2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered
3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)
7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Based on observation and interview, it was determined the facility lacked a complete automatic sprinkler system required for this building construction type.
Findings include:
1. Observation on January 31, 2024, at 9:55 am, revealed the facility lacked a complete automatic sprinkler system.
Exit interview with the facilities manager and maintenance representative on January 31, 2024, at 11:00 am, confirmed the component lacked a complete automatic sprinkler system.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System (FSES) be completed by Pennsylvania Department of Health Division of Safety Inspection.
NFPA 101 STANDARD
Interior Wall and Ceiling Finish
Name - BUILDING 02 Component - 02
Interior Wall and Ceiling Finish
2012 EXISTING
Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2
Indicate flame spread rating(s). _____________________
Observations:
Based on observation and interview it was determined the facility failed to maintain the required wall finish flame spread rating of Class A or B.
Findings include:
1. Observation on January 31, 2024, at 10:00 am, revealed the office and dining rooms had paneling installed on the walls.
Exit interview with the facilities manager and maintenance representative on January 31, 2024, at 11:00 am, confirmed the paneling was a Class C finish material.
Plan of Correction:An approved fire-retardant coating complying with NFPA 101-2012 Edition; 10.2.6 will be applied to the walls to achieve compliance with flame spread rating.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID# 12601100
Component 03
423 Building
Based on a Medicaid Recertification Survey completed on January 31, 2024, it was determined that Allied Health Care Services Inc.-Lynett Village, was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type V (000), unprotected, wood frame building, that is not sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - BUILDING 03 Component - 03
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5
Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered
2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered
3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)
7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Based on observation and interview, it was determined the facility lacked a complete automatic sprinkler system required for this building construction type.
Findings include:
1. Observation on January 31, 2024, at 10:20 am, revealed the facility lacked a complete automatic sprinkler system.
Exit interview with the facilities manager and maintenance representative on January 31, 2024, at 11:00 am, confirmed the component lacked a complete automatic sprinkler system.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System (FSES) be completed by Pennsylvania Department of Health Division of Safety Inspection.
NFPA 101 STANDARD
Interior Wall and Ceiling Finish
Name - BUILDING 03 Component - 03
Interior Wall and Ceiling Finish
2012 EXISTING
Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2
Indicate flame spread rating(s). _____________________
Observations:
Based on observation and interview, it was determined the facility failed to maintain the required wall finish flame spread rating of Class A or B.
Findings include:
1. Observation on January 31, 2024, at 10:15 am, revealed the office and dining rooms had paneling installed on the walls.
Exit interview with the facilities manager and maintenance representative on January 31, 2024, at 11:00 am, confirmed the paneling was a Class C finish material.
Plan of Correction:An approved fire-retardant coating complying with NFPA 101-2012 Edition; 10.2.6 will be applied to the walls to achieve compliance with flame spread rating.
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