QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on January 16, 2019, at BARC Hellertown Avenue, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.

Plan of Correction:

Initial Comments:
Name - ICF IMPRACTICAL Component - 01

Facility ID # 24421101
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on January 16, 2019, it was determined that BARC Hellertown Avenue 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:

Sprinkler System - Maintenance and Testing

Name - ICF IMPRACTICAL Component - 01
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


Based on observation and interview, it was determined the facility failed to maintain the required spare sprinkler inventory for automatic sprinkler system, affecting the entire facility.

Findings include:

1. Observation made on January 16, 2019 at 9:25 am, revealed in the basement, the sprinkler spares box mounted near the sprinkler riser contained only 5 spare sprinklers instead of the required 6 spares.

Interview at the exit conference with the Maintenance Supervisor on January 16, 2019, at 9:35 am, confirmed the box contained only 5 spare sprinklers.

Plan of Correction:

A additional sprinkler head will be stored in the sprinkler fire box for a total of 6. The sprinkler fire box will be checked monthly to ensure the correct amount of 6 extra sprinkler heads are stored .