Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 30, 2024, at Merakey Allegheny Valley School Valley Road, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - (IMPRACTICAL) MAIN BUILDING Component - 01
Facility ID# 22151101
Component 01
Based on a Medicaid Recertification Survey completed on January 30, 2024, it was determined that Merakey Allegheny Valley School Valley 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
General Requirements - Other
Name - (IMPRACTICAL) MAIN BUILDING Component - 01
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 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:
Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage, affecting the entire facility.
Findings include:
Observation on January 30, 2024, at 9:30 a.m., revealed an unsecured " E-size " Oxygen cylinder in the dining area.
Refer to NFPA 99, 11.6.2.3.
Interview at the exit conference with the House Manager and Maintenance Director on January 30, 2024, at 10:15 a.m., confirmed the unsecured oxygen cylinder.
Plan of Correction:On 1/30/2024 the oxygen cylinder was moved and secured upon House manager observation as well.
On or before 2/14/24 the house manager will retrain all staff in securing and storage of oxygen tanks. Training will be sent to the Associate Executive director for verification.
As of 1/30/2024 House Manager will do daily checks to ensure that the oxygen cylinders are stored properly. Any anomalies will be addressed immediately.
As of 1/30/24 the Community Director or designees will do audits of the home to ensure that the oxygen cylinders are stored properly. Any anomalies will be addressed immediately.
|