Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on July 10, 2024, at BARC Developmental Services Inc. Old Bethlehem II, 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# 28391100
Component 01
Old Bethlehem II
Based on a Medicaid Recertification Survey completed on July 10, 2024, it was determined that BARC Developmental Services Inc. Old Bethlehem II, 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 Impractical.
Plan of Correction:
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - IMPRACTICAL Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
Observations:
Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels.
Findings include:
Observation on July 10, 2024, at 9:50 a.m., revealed exposed wires protruding from the wall by the electrical panel in the basement.
Exit Interview with the Administrator and Maintenance Director on July 10, 2024, at 10:20 a.m., confirmed the exposed wiring.
Plan of Correction:The exposed wire was removed. Prior to removal it was determined that it was not needed and was also not a live / hot wire.
Every quarter, the Maintenance Technician will review the electrical panel areas to ensure that no exposed wires are present. In the event that any exposed wires are discovered, they will be removed immediately.
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