Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on August 10, 2023, at Melmark Inc, Berwyn, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - (IMPRACTICAL) MELISSA A AND B Component - 01
Facility ID# 18871101
Component 01
Melissa A & B
Based on a Medicaid Recertification Survey completed on August 10, 2023, at Melmark Inc, Berwyn- Melissa A & B, were 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 III (211), protected ordinary construction, which is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Fire Drills
Name - (IMPRACTICAL) MELISSA A AND B Component - 01
Fire Drills
1. The facility must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to:
a. Ensure that all personnel on all shifts are trained to perform assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use of the facility's emergency and disaster plans and procedures.
2. The facility must:
a. Actually evacuate clients during at least one drill each year on each shift;
b. Make special provisions for the evacuation of clients with physical disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including accidents and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of this section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Observations:
Based on document review and interview, it was determined the facility failed to perform one of twelve required fire drills.
Findings include:
1. Document review on August 10, 2023, at 9:00 am, revealed the facility could not provide documentation that a fire drill was conducted for Melissa A, 3rd shift, 1st quarter 2023.
Exit interview with the Maintenance Director on August 10, 2023, at 11:15 am, confirmed the missing documentation.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disability Professionals (QIDP) and House Supervisors of Melissa A House will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 09/15/2023.
Melissa A House will conduct a fire drill on the 3rd shift, defined as 11:00 PM to 7:00 AM. The time of the fire drill will be varied from the previous fire drills conducted in the course of the year. The fire drill will occur any day in the month of October 2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents of Mellissa A House.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Qualified Intellectual Disability Professionals (QIDP) and House Supervisors of Melissa A House will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 09/15/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All QIDP and House Supervisors of the facility will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 09/15/2023.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: All Assistant Directors of the facilities will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 09/15/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All Assistant Directors of the facilities will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 09/15/2023.
The Assistant Director or designee will be trained on how review fire drills once conducted. The review of completed monthly drills will need to be completed by the 15th date of each month to verify that the fire drill was completed at the scheduled shift and varied time as per the fire drill schedule. If the Assistant Director identifies a fire drill that was not conducted during the correct shift and time, the facility will conduct another fire drill as per the fire drill schedule by the end of the specific month in review. This practice will begin in the month of September 2023.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate timeline as outlined in the plan of correction. This will be accomplished through monthly meetings to review the status of corrective action completion, beginning 09/01/2023. Additionally, the Director of the facility will ensure continued compliance and oversight of all fire drill processes moving forward. This will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
Initial Comments:
Name - I(MPRACTICAL) COTTAGE #20 SPRUCE A AND B Component - 02
Facility ID# 18871101
Component 02
Cottage #20 Spruce A & B
Based on a Medicaid Recertification Survey completed on August 10, 2023, at Melmark, Inc. Berwyn, it was determined there were no deficiencies identified under the 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 III (211), protected ordinary structure, which is fully sprinklered.
State Plans approved as Impractical.
Plan of Correction:
Initial Comments:
Name - (IMPRACTICAL) ENGLE HOUSE Component - 03
Facility ID# 18871101
Component 03
Engle House
Based on a Medicaid Recertification Survey completed on August 10, 2023, it was determined that Melmark Engle House 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 II (000), unprotected non-combustible construction, which is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Fire Drills
Name - (IMPRACTICAL) ENGLE HOUSE Component - 03
Fire Drills
1. The facility must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to:
a. Ensure that all personnel on all shifts are trained to perform assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use of the facility's emergency and disaster plans and procedures.
2. The facility must:
a. Actually evacuate clients during at least one drill each year on each shift;
b. Make special provisions for the evacuation of clients with physical disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including accidents and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of this section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Observations:
Based on document review and interview, it was determined the facility failed to perform one of twelve required fire drills.
Findings include:
1. Document review on August 10, 2023, at 9:00 am, revealed the facility could not provide documentation that a fire drill was conducted for Engle House, 1st shift, 2nd quarter 2023.
Exit interview with the Maintenance Director on August 10, 2023, at 11:15 am, confirmed the missing documentation.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
Engle House will conduct a fire drill on the first shift, defined as 7:00 AM to 3:00 PM. The time of the fire drill will be varied from the previous fire drills conducted in the course of the year. The fire drill will occur any day in the month of September 2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents of Engle House.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Qualified Intellectual Disability Professionals (QIDP) and House Supervisors of Engle House will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 09/15/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. The QIDP and House Supervisors of the facility will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 08/31/2023.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: All Assistant Directors of the facilities will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 09/15/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All Assistant Directors of the facilities will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 09/15/2023.
The Assistant Director or designee will be trained on how review fire drills once conducted. The review of completed monthly drills will need to be completed by the 15th date of each month to verify that the fire drill was completed at the scheduled shift and varied time as per the fire drill schedule. If the Assistant Director identifies a fire drill that was not conducted during the correct shift and time, the facility will conduct another fire drill as per the fire drill schedule by the end of the specific month in review. This practice will begin by 09/15/2023.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate timeline as outlined in the plan of correction. This will be accomplished through monthly meetings to review the status of corrective action completion, beginning 09/01/2023. Additionally, the Director of the facility will ensure continued compliance and oversight of all fire drill processes moving forward. This will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
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