Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on Febraury 24, 2026, at Merakey Allegheny Valley School Patricia Hillman Miller Campus, 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# 01381100
Component 01
East and North Wing
Based on a Medicaid Recertification Survey completed on February 24, 2026, it was determined that Merakey Allegheny Valley School Patricia Hillman Miller Campus 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 three-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation and interview, it was determined the facility failed to obtain approval from the Division of Safety Inspection, Plan Review Department, prior to conducting rehabilitation work in one instance, affecting three of four floors.
Findings include:
1. Observation February 24, 2026, at 9:45 a.m. revealed that work was being performed to the wash/changing rooms on all three floors. There were no state approved plans onsite.
Interview with the Facility Administrator and Maintenance Director on February 24, at 12:30 p.m., confirmed that Plan Review had not been contacted prior to beginning the rehabilitation project.
Plan of Correction:On 2/24/26, Senior Director notified Merakey Director of Facilities Management of the Division of Safety Inspection requirement for Plan Review and Approval for Rehabilitation work on 3 of 4 floors.
On 2/24/26, Merakey Director of Facilities Management notified Architect regarding submission of plan for review to the Division of Safety Inspection for the Rehabilitation work on 3 of 4 floors.
On or before 3/20/26, the Architect will submit plans for approval to the Division of Safety Inspection for the Rehabilitation work on Apartment 1,2 and 3.
Merakey Director of Facilities will ensure plans will be submitted for review and approval by the Division of Safety Inspection for all future Rehabilitation Work.
NFPA 101 STANDARD
Building Construction Type and Height
Name - MAIN BUILDING 01 Component - 01
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 failed to maintain the required building construction type throughout the facility.
Findings include:
1. Observation on February 24, 2026, at 9:00 a.m., revealed the facility construction type is a three-story, Type III (200), unprotected ordinary structure with a basement that is fully sprinklered. This type of construction is not permitted to be more than two stories.
Interview with the Facility Administrator and Maintenance Director on February 24, 2026, at 12:30 p.m., confirmed the construction type deficiency.
Plan of Correction:Request FSES and time limited Waiver
NFPA 101 STANDARD
Means of Egress - General
Name - MAIN BUILDING 01 Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Based on observation and interview, it was determined the facility failed to maintain a clear and unobstructed egress path within an exit stairway enclosure in one instance, affecting one of eight smoke compartments.
Findings include:
1. Observation on February 24, 2026, at 10:15 a.m., revealed the ground floor of the center stairwell was being used for storage.
Interview with Facility Administrator and Maintenance Director on February 24, 2026, at 12:30 p.m., confirmed the above listed stairwell enclosure deficiency.
Plan of Correction:On 2/24/26, Asst. Program Director removed all items stored under center stairwell.
On 2/24/26, Senior Director checked that their was no equipment stored under any of the remaining stairwells.
On 3/3/26, Senior Director trained Program Staff on the importance of not storing items under stairwells.
Senior Director during routine physical plant walk through will check for storage under stairwells. If detected, Senior Director will address and remove.
NFPA 101 STANDARD
Number of Exits - Story and Compartment
Name - MAIN BUILDING 01 Component - 01
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Based on observation and interview, it was determined the facility failed to provide not less than two exits, remote from each other, from every part of every story of the building.
Findings include:
1. Observation on February 24, 2026, revealed the following exiting deficiencies:
a) 9:15 a.m., the second means of egress from the second and third floor in the East Building requires exiting through a communicating stair tower;
b) 9:25 a.m., the Program Directors office in the East Building is located within the communicating stair tower.
Interview with the Facility Administrator and Maintenance Director on February 24, 2026, at 12:30 p.m., confirmed the exiting deficiencies.
Plan of Correction:Requesting approval to utilize the F.S.E.S performed during annual survey.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 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
Observations:
Based on observation, document review, and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting the entire facility.
Findings include:
1. Observation and document review on February 24, 2026, revealed the following automatic sprinkler deficiencies:
a) 8:35 a.m., the facility failed to provide the documentation for a current five-year internal pipe inspection and five-year internal valve inspection of the automatic sprinkler system;
b) 9:20 a.m., there was a sprinkler head missing a sprinkler cap in the basement;
c) 9:40 a.m., the were gaps in the ceiling tile around piping in the basement.
Interview with the Facility Administrator and Maintenance Director on February 24, 2026, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:On 2/24/26, Fire Protection Inc. was contacted regarding the 5 year sprinkler test.
On 3/19/26, Fire Protection Inc is scheduled to conduct 5 year sprinkler test.
On 2/25/26, Maintenance replaced the cover on the sprinkler head.
On 3/3/26, Maintenance filled the gaps around the piping in the basement
The Maintenance Supervisor or designee will complete quarterly checks on sprinkler heads and gaps around the piping. If sprinkler heads are missing or gaps detected, repairs will be made.
The Senior Director during monthly physical plant walk through will look for missing sprinkler heads or gaps around piping. If detected, a Maintenance Request will be completed for repair.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID# 01381100
Component 03
West Wing
Based on a Medicaid Recertification Survey completed on February 24, 2026, at Merakey Allegheny Valley School-Patricia Hillman Miller Campus, 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 three-story, Type II (222), fire resistive building, with a basement, that is not sprinklered.
Plan of Correction:
|