Initial Comments:
Name - Component - --Based on an Emergency Preparedness Survey completed on April 8, 2026, at Merakey Allegheny Valley School Cherry Lane, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - IMPRACTICAL Component - 01Facility ID# 19751101Component 01 Cherry Lane Based on a Medicaid Recertification Survey completed on April 8, 2026, it was determined that Merakey Allegheny Valley School Cherry Lane 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 two-story, Type V (000), unprotected wood frame construction, with a basement and unused attic space, which is fully sprinklered. State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Means of Egress - General
Name - IMPRACTICAL Component - 01
Means of Egress - General
2012 EXISTING
Means of egress from dwelling units to the outside of the building are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency.
Means of escape within a resident room or resident dwelling unit complies with 24.2 for one- and two-family dwellings.
31.2.1
Observations:
Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments to full and instant use, affecting one exit discharge.
Findings include:
1. Observation on April 8, 2026, at 10:15 a.m., revealed, the front entrance stairs had signs of spalling, minimally exposed rebar and a large hole in the riser, creating a tripping hazard.
Exit Interview with the Administrator and Maintenance Director on April 8, 2026, at 11:15 a.m., confirmed the stair condition.
Plan of Correction:On 4/15/2026 the stairs leading into the front entrance were repaired/replaced.
As of 4/8/26 the Program Lead will do a monthly walk thru to ensure that the facility is maintaining the means of egress free of impediments. Any anomalies will be reported to facilities for repair. Any anomalies will be addressed by Facilities within 14 days.
As of 4/15/26 the Program Manager or Designee Department will do a monthly walk thru to ensure that facility is maintaining the means of egress free of impediments. Any anomalies will be reported to the Program Lead and facilities for repair. Any anomalies will be addressed by Facilities within 14 days.
As of 4/15/2026 the Facilities Department will do a walk through quarterly to that facility is maintaining means of escape that are clear of obstructions. Any anomalies will be addressed by Facilities within 14days.
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