Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 28, 2024, at Merakey Allegheny Valley School Norristown Road, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475
Plan of Correction:
Initial Comments:
Name - (MAIN BUILDING) IMPRACTICAL Component - 01
Facility ID# 22441101
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on March 28, 2024, it was determined Merakey Allegheny School AVS Norristown Road 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, with a basement, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - (MAIN BUILDING) IMPRACTICAL Component - 01
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.
Findings include:
1. Observation on March 28, 2024, at 12:15 pm, revealed the December 15, 2023, Fire Alarm inspection report did not include testing of the attic heat detectors.
Exit Interview with the House Manager and Maintenance Supervisor on March 8, 2024, at 1:15 pm, confirmed the omission.
Plan of Correction:On 4/8/24 Director of facilities reached out to Guardian Protection to have attic heat detectors tested that were not completed on 12/15/24 to be completed by 4/30/24. Once the testing is completed it should be added to the Fire Alarm inspection report.
As of 4/30/24 the Facilities supervisor will review all inspection reports upon completion to ensure that all heat detectors are noted in the inspection report as being completed. Any anomalies will be followed up with inspectors within 7 days for completion.
As of 4/30/24 the Facilities Director will ensure that all inspection reports have included all heat detectors in the home and are included on reports.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - (MAIN BUILDING) IMPRACTICAL Component - 01
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review and interview, it was determined the facility failed to maintain sprinkler components, affecting one of two levels.
Findings include:
1. Observation on March 28, 2024, at 12:40 pm, revealed, in the front entrance closet, household items were stored directly under and within 18 inches of the sprinkler.
Exit Interview with the House Manager and Maintenance Supervisor on March 28, 2024, at 1:15 pm, confirmed the obstructed sprinkler.
Plan of Correction:On 3/28/24 all household items were removed from being directly under and within 10 inches of the sprinkler components.
As of 4/1/24 the House Manager will do weekly walk throughs to ensure that there are not any objects directly under or within 10 inches of the sprinkler components. Any anomalies will be addressed upon observation and removed from the area where the sprinkled system is being obstructed.
As of 4/1/24 the Community Team Supervisor will conduct a monthly walk through to ensure that there are no objects directly under or within 10 inches of the sprinkler components. Any anomalies will be addressed upon observation and removed from the area where the sprinklered system is being obstruction.
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