Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on February 12, 2024, at Merakey Allegheny Valley School Big Oak Road, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - IMPRACTICAL Component - 01
Facility ID# 18781101
Component 01
Based on a Medicaid Recertification Survey completed on February 12, 2024, it was determined that Merakey Allegheny Valley School Big Oak 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 construction, with a basement, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - IMPRACTICAL 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:
28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES
Governing body responsibilities include:
(1) Conforming to applicable Federal, State, and local law. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained, and operated to safely and efficiently render the services offered.
Based on observation, document review and interview, it was the facility failed to obtain proper approval for renovations, affecting one of two levels.
Findings include:
Observation and document review on February 12, 2024, at 9:30 a.m. revealed the facility failed to secure plan approval by the Department of Health prior to installation of a new concrete exit ramp at the rear of the home.
Exit Interview with the House Manager and Maintenance Director on February 12, 2024, at 10:00 a.m., confirmed that the facility failed to obtain plan approval for the new ramp.
28 Pa Code 51.3. Notification (d)
Plan of Correction:The facility will obtain that proper approval for renovations, affecting one of two levels is completed.
On or before 3/15/2024 the Facilities Director will submit a plan for approval to the Department of health. Once the plan is approved Facilites director will schedule inspection.
Here after all future projects that a plan of approval prior to construction will be Sent by the facilities Director.
As of 3/1/2024 the Director of the Eastern Region Facilites will ensure that any projects that need inspection will have plans submitted accordingly.
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