Initial Comments:
A focused fundamental survey was conducted February 4-5, 2026, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was four and the sample consisted of two individuals.
Plan of Correction:
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on review of fire drill documentation and interview, it was determined that the facility failed to ensure that fire drills were conducted under varied conditions. This applied to all the individuals at the residence. Findings included:
A review of facility provided documentation of the fire drills for the past year was completed on February 4, 2026. This review revealed that two of the three facility exits were practiced in the past 12 months. However this review failed to reveal that the third exit, the front door, was practiced. During an interview with the program lead on February 4, 2026, at 4:00 PM, the program lead confirmed that the front door exit was not practiced in the past 12 months during any of the fire drills.
Interview with the administrator on February 5, 2026, at 8:30 AM confirmed that it is the expectation that all exits at the facility should be practiced for fire drill evacuations.
Plan of Correction:Merakey Allegheny Valley School (AVS), 357 Keister Road, Slippery Rock, Pa. 16057 makes its best effort to operate in full compliance with both Federal and State law. Nothing included in this Plan of Correction is an admission otherwise. Merakey AVS, 357 Keister Road has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to its merits or form of any allegations contained herein. Please note that Merakey AVS, 357 Keister Road may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
TAG #:0441
On 2/6/26, the Program Lead and the Program Manager were retrained by the Senior Director on ensuring that fire evacuation drills are practiced under varied circumstances. Emphasis was placed on all of the designated exits in the home being practiced throughout the year during the Monthly Fire Drills. A Staff Attendance Sheet was signed to acknowledge their participation in the training.
On 2/17/26, a tracking form was developed and shared with the Program Lead to maintain a record of the designated exits utilized during the Monthly Fire Drills and to ensure that all designated exits are being practiced throughout the year.
By 2/20/26, the Program Lead will retrain the Direct Care Staff who work at 357 Keister Road on the evacuation procedures during a fire drill and the utilization of the designated exits of the house. Staff will sign a Staff Attendance Sheet acknowledging they were retrained on the evacuation procedures at 357 Keister Road and any questions or concerns were addressed.
During the month of March 2026, the Program Lead will conduct an unannounced Monthly Fire Drill at 357 Keister Road. The fire drill will be documented on the Monthly Fire Drill form verifying that the front door was utilized to successfully evacuate the home safely. In addition, the Program Lead will begin utilizing the tracking form to track the designated exits that were utilized during the Monthly Fire Drills to monitor that all designated exits are practiced throughout the year.
The Program Manager and/ or designee will review the fire drills that are completed monthly along with the tracking document to monitor the designated exits are being practiced throughout the year.
On 2/17/26, the Butler/Mercer Program Leads and Program Managers were reminded via an e-mail sent from the Senior Director that all designated exits are to be practiced under varied conditions during the monthly fire drills. The tracking form was shared with the Butler/Mercer Program Leads and Program Managers and they were instructed to document on the form what designated exits were utilized during each Monthly Fire Drill.
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