Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on November 21, 2023, at Merakey Allegheny Valley School-Brodhead 2, , it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - ALLEGHENY VALLEY SCHOOL BRODHEAD AND CALER Component - 01
Facility ID# 23851101
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on November 21, 2023, it was determined that Merakey Allegheny Valley School-Brodhead 2, 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, with a basement, that is fully sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - ALLEGHENY VALLEY SCHOOL BRODHEAD AND CALER 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 the automatic sprinkler system in one instance, in one of more than 10 rooms inspected.
Findings include:
1. Observation on November 21, 2023, at 9:50 a.m., revealed an electrical wire resting on a sprinkler line in the basement.
Interview with the Administrator and House Manager on November 21, 2023, at 10:30 a.m., confirmed the automatic sprinkler system deficiency.
Plan of Correction:Allegheny Valley School Brodhead 2 SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Brodhead 2 SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Brodhead 2 SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
On 11/21/23, a maintenance work order was placed by the House Manager of the Brodhead 2 home regarding the electrical wire resting on the basement sprinkler line. A maintenance technician completed this repair on 11/22/23 by tacking the electrical line to the ceiling so that it was no longer resting on the sprinkler line.
For all other potentially affected areas, all House Managers in the Allegheny and Beaver ICF homes received training on maintaining the automatic sprinkler systems at the monthly House Manager meeting which occurred on 11/21/23. Specific emphasis was placed on ensuring that no wires or any other items are touching sprinkler lines. Signed training sheets will be maintained by the Administrator.
Monitoring will be on-going, occurring monthly by ICF Administrator.
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