Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on Febraury 21, 2024, 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 21, 2024, 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
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 21, 2024, 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 21, 2024, at 9:00 a.m., confirmed the construction type deficiency.
Plan of Correction:Requesting approval to utilize the F.S.E.S performed during the annual survey.
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 21, 2024, 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 21, 2024, at 9:25 a.m., confirmed the exiting deficiencies.
Plan of Correction:Requesting approval to utilize the F.S.E.S performed during the annual survey.
NFPA 101 STANDARD
Cooking Facilities
Name - MAIN BUILDING 01 Component - 01
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
Observations:
Based on observation and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of eight smoke compartments.
Findings include:
1. Observation and document review on February 21, 2024, at 8:55 a.m., revealed that the facility lacked documentation for the semi annual kitchen suppression inspection due in May 2023.
Interview with the Facility Administrator and Maintenance Director on February 21, 2024, at 8:55 a.m., confirmed the kitchen suppression system deficiency.
Plan of Correction:November 2023, the semi-annual kitchen suppression system was inspected by ABCO Fire Protection.
On 2/21/2024, Maintenance Supervisor contacted ABCO Fire Protection to ensure PHMC is scheduled for semi-annual inspection of the kitchen suppression system. Representative from ABCO confirmed Merakey Allegheny Valley School PHMC is on the schedule for semi-annual inspections.
On or before 3/15/2024, the Administrator will train Maintenance Staff on the importance of scheduling and ensuring the semi-annual inspection of the kitchen suppression system is completed.
Maintenance Supervisor and Administrator will monitor the semi-annual inspections of the kitchen suppression system is completed.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.
Findings include:
1. Review of documentation on February 21, 2024, revealed the facility lacked documentation verifying the following items were performed in the last 12 and 36 months:
a) 8:30 a.m., the annual 90 minute load bank test;
b) 8:45 a.m., the three year, four hour test.
Interview with the Facility Administrator and Maintenance Director, on February 21, 2024, at 8:45 a.m., confirmed the required yearly and three year generator testing documentation was not available at the time of the survey.
Plan of Correction:On 2/24/24, Curtis Power Solutions completed the four (4) hour load test with no concerns.
On or before 3/15/2024, the Administrator will train Maintenance Staff on the importance of ensuring the
annual 90 minute load bank test and the three year four hour test are scheduled and completed.
The Administrator and Maintenance Supervisor will monitor the annual 90 minute load bank test and the three year four hour test is completed.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID# 01381100
Component 03
West Wing
Based on a Medicaid Recertification Survey completed on February 21, 2024, 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 II (222), fire resistive building, with a basement, that is not sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - BUILDING 03 Component - 03
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.
Findings include:
1. Review of documentation on February 21, 2024, revealed the facility lacked documentation verifying the following items were performed in the last 12 and 36 months:
a) 8:30 a.m., the annual 90 minute load bank test;
b) 8:45 a.m., the three year, four hour test.
Interview with the Facility Administrator and Maintenance Director, on February 21, 2024, at 8:45 a.m., confirmed the required yearly and three year generator testing documentation was not available at the time of the survey.
Plan of Correction:On or before 3/15/2024, the Administrator will train Maintenance Staff on the importance of ensuring the proper documentation is obtained for the
annual 90 minute load bank test and the three year four hour test.
The Administrator and Maintenance Supervisor will monitor documentation is obtained for the annual 90 minute load bank test and the three year four hour test.
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