Initial Comments:
A focused fundamental survey visit was completed on May 8 and 9, 2023. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was four and the sample consisted of two individuals.
Plan of Correction:
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on a review of facility documention and interview with administrative staff,
the facility failed to ensure evacuation drills were conducted at least quarterly for each shift of personnel.
Findings included:
A review of evacuation drills was completed on May 9, 2023 from 8:45 AM to 9:15 AM. This review revealed that the facility utilizes a calendar quarterly basis, e.g. January through December, on which per shift fire drill activity is conducted. In review of fire drills conducted for the period from April, 2022 through March, 2023, the following: was identified:
- for the period from April, 2022 through June, 2022 there were no fire drills completed for the second and third shift of personnel.
- for the period from July, 2022 through September, 2022 there was no fire drill completed for the second shift of personnel.
Interview with the house manager on May 9, 2023 at approximately 9:20 AM, confirmed
that fire drills were not conducted as outlined in the residence fire drill schedule.
Plan of Correction:Merakey Allegheny Valley School Frankford (MAVSF) 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. MAVS 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 MAVSF may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
C1
On or before May 30 , 2023, the Associate Executive Director or designee will retrain all House Managers regarding State and Federal regulations and agency policies pertaining to fire drills/emergency evacuations. The training will emphasize conducting and documenting a fire drill on each shift (1st, 2nd, and 3rd shifts) every quarter, varying the times to cover the entire shift. The time of the fire drill will be identified by writing in the time of the drill within the shift identifier section at the bottom of the form. The time of the drill will also be indicated in the description by stating that the drill was performed on 1st, 2nd, or 3rd shift. The House Manager must follow the Fire drill guideline schedule and the target completion date of the 15th of the month to ensure ample time for completion and to be able to perform another fire drill if missed or needs to be repeated. The training will be documented on a Staff Attendance Sheet to verify completion. The Staff Attendance sheet will be filed in the Staff Development department and a copy will be forwarded to the Executive Director to verify completion.
C2
On or before June 15, 2023, the House Manager will conduct a fire drill in accordance with the fire drill scheduling guideline. This fire drill/emergency evacuation will be documented on a Monthly Fire Drill Report form and submitted to the Evacuation Drill Verification System(EDVS). The Monthly Fire Drill Report will be submitted to the Community Director through the Evacuation Drill Verification System (EDVS). The CD will review the Monthly Fire Drill Report and will approve or reject the Report ensuring that all pertain data has been completed; date, time, asleep or awake drill, evacuation time, shift drill conducted, exit route, etc. If the Report is rejected for lack of information, the House Manage will have five days to correct and resubmit the report. If concerns are identified with the varied conditions and/or the scheduling guidelines were not followed, the Community Director will require that another drill be conducted to maintain compliance with State and Federal regulations and agency policy.
C3
The House Managers receive monthly automated email alerts of upcoming fire drills for their respective location(s). These alerts will include all relevant information about the drill such as the date due, recommended shift, and time of the drill. The automated alerts will be scheduled to be sent on the 1st of each month and one day prior to the 15th of the month. If a fire drill has not been submitted by the 16th of the month, an automated email alert will trigger that the fire drill task is now outstanding. These alerts will be sent every two days until the task has been completed. The Associate Executive Director and the Community Director will be copied on the outstanding automated alerts. The Monthly Fire Drill Report form will be submitted to the Community Director through the Evacuation Drill Verification System (EDVS) by the 15th of the month. The Community Director will review the Monthly Fire Drill Report as they are submitted and will approve or reject the Report ensuring that all pertain data has been completed; date, time, asleep or awake drill, evacuation time, shift drill conducted, exit route, etc. If the Report is rejected for lack of information or needs correction, the House Manage will have five days to correct and resubmit the Report. If concerns are identified with the varied conditions and/or the scheduling guidelines were not followed, the Community Director will require that another drill be conducted to maintain compliance with State and Federal regulations and agency policy. Any concerns noted will be addressed with further training and/or disciplinary action.
C4
The House Managers will complete the Fire Drill Review form for each quarter. The Fire Drill Review form will identify the date, time, asleep or awake drill, evacuation time, shift drill conducted, exit route for each shift during the quarter. The Associate Executive Director or designee will review the quarterly Fire Drill Review form to ensure that all fire drills were completed and documented within that quarter maintaining State and Federal regulations and agency policies pertaining to fire drills/emergency evacuations. If any concerns are identified, the Associate Executive Director or designee will require another drill to be conducted to maintain compliance. The quarterly reviews will confirm that the House Manager is varying the times and days of evacuation drills, according to State and Federal regulations and the agency's fire drill guidelines based on the approval of the CD. Any anomalies will be addressed with training and corrective action.
C5
The Associate Executive Director will present a summary of all audit outcomes to the Senior Executive at the monthly executive meeting chaired by the Senior Executive Director, who will address any outlying issues with systemic corrective actions.
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