Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 19, 2024, at Melmark Homes Cottage #18 Miller A, 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# 20791101
Component 01
Cottage #18 Miller A
Based on a Medicaid Recertification Survey completed on March 19, 2024, it was determined that Melmark Homes Cottage #18 Miller A 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 III (211), protected ordinary building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - IMPRACTICAL Component - 01
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of three gauges.
Observation on March 19, 2024, at 9:50 a.m., revealed, in the sprinkler room, a sprinkler gauge was dated 2018, exceeding the 5-year service interval. Evidence of calibration was not available at time of survey.
Exit Interview with the Administrator and Facilities Director on March 19, 2024, at 10:15 a.m., confirmed the gauge was beyond the 5-year service interval.
Plan of Correction:1. The sprinkler gauge dated 2018 was replaced on March 19, 2024.
2. During the Life and Safety inspection, all sprinkler components in the home were inspected. Only one gauge was identified as being out of compliance. The one identified gauge was replaced on March 19, 2024.
3. All sprinkler system gauges will be inspected by Melmark's Life and Safety Inspector at least monthly. This will be documented on the comment section of the Environmental Monthly Checklist, under Fire Safety. If a gauge is noted to be at 6 months to it's 5-year service interval, the Life and Safety Inspector will notify the Director of Facilities within 24 hours of discovery. The Director of Facilities or a designee will ensure the gauge is replaced prior to exceeding the 5-year service interval.
4. The Director of the facilities department of a designee will review the sprinkler system gauge inspection check completed by the Melmark Life and Safety Inspector on a monthly basis.
5. The Director of Facilities and the Director of the Miller A Facility are responsible for ensuring that all corrective actions are completed by the appropriate time line as outlined in the plan of correction. If the plan of correction is not carried out as outlined, the Director of the facility will ensure the appropriate items are followed up on as outlined and will issue corrective action in accordance with Melmark's Corrective Action Policy.
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