Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 21, 2021, at Allied Health Care Services Inc.- Lynett Village, 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# 12601100
Component 01
421 Building
Based on a Medicaid Recertification Survey completed on January 21, 2021, it was determined that Allied Health Care Services Inc.-Lynett Village, 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, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Aisle, Corridor, or Ramp Width
Name - MAIN BUILDING 01 Component - 01
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the required exit corridor width in one instance, affecting one of one floors in this component.
Findings include:
1. Observation on January 21, 2021, at 10:15 a.m., revealed the exit corridor, adjacent to the kitchen, was reduced to less than four feet in width as it passes through the cross-corridor door.
Exit interview with the facilities manager on January 21, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the reduced corridor width.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System be completed.
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID# 12601100
Component 02
422 Building
Based on a Medicaid Recertification Survey completed on January 21, 2021, it was determined that Allied Health Care Services Inc.-Lynett Village, 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, that is nonsprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - BUILDING 02 Component - 02
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 lacked a complete automatic sprinkler system required for this building construction type.
Findings include:
1. Observation on January 21, 2021, at 10:35 a.m., revealed the facility lacked a complete automatic sprinkler system.
Exit interview with the facilities manager on January 21, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the component lacked a complete automatic sprinkler system.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System be completed.
NFPA 101 STANDARD
Aisle, Corridor, or Ramp Width
Name - BUILDING 02 Component - 02
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the required exit corridor width in one instance, affecting one of one floors in this component.
Findings include:
1. Observation on January 21, 2021, at 10:40 a.m., revealed the exit corridor, adjacent to the kitchen, was reduced to less than four feet in width as it passes through the cross-corridor door.
Exit interview with the facilities manager on January 21, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the reduced corridor width.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System be completed.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID# 12601100
Component 03
423 Building
Based on a Medicaid Recertification Survey completed on January 21, 2021, it was determined that Allied Health Care Services Inc.-Lynett Village, 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, that is nonsprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - BUILDING 03 Component - 03
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 lacked a complete automatic sprinkler system required for this building construction type.
Findings include:
1. Observation on January 21, 2021, at 10:55 a.m., revealed the facility lacked a complete automatic sprinkler system.
Exit interview with the facilities manager on January 21, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the component lacked a complete automatic sprinkler system.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System be completed.
NFPA 101 STANDARD
Aisle, Corridor, or Ramp Width
Name - BUILDING 03 Component - 03
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the required exit corridor width in one instance, affecting one of one floors in this component.
Findings include:
1. Observation on January 21, 2021, at 10:55 a.m., revealed the exit corridor, adjacent to the kitchen, was reduced to less than four feet in width as it passes through the cross-corridor door.
Exit interview with the facilities manager on January 21, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the reduced corridor width.
Plan of Correction:Facility requests that a new Fire Safety Evaluation System be completed.
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