Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 12, 2024, at Merakey Allegheny Valley School Lindbergh, 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# 34661100
Component 01
Based on a Medicaid Recertification Survey completed on January 12, 2024, it was determined that Merakey Allegheny Valley School Lindbergh, 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 an attic, which 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 protection of sprinkler components, affecting 1 of approximately fourteen rooms.
Findings Include:
Observation made on January 12, 2024, at 11:19 a.m., revealed the sprinkler head inside the laundry room was used to support a hanger and clothing.
Exit Interview with the Community Director, House Manager and Maintenance Director on January 12, 2024, at 11:30 a.m., confirmed the obstruction of the protection equipment.
Plan of Correction:On January 12, 2024, the Community Director immediately retrained the House Manager on
maintaining the protection of the sprinkler component. The training emphasized at no time should
objects hang, cover or block any of the sprinklers, as it is important to keep all sprinklers free and clear for proper use. This training was documented on a Staff Attendance Sheet and a copy sent to the Associate Executive Director to verify completion. A copy of the training will be maintained in the Emergency Preparedness Plan binder under the "training " section of the book.
On or before February 18,2024, the House Manager will retrain the facility staff on maintaining the protection of the sprinkler component. The training will emphasize that it is prohibited to hang, cover, or block any of the sprinklers to include but limited to hanging clothing in the laundry room or any item (s) on a sprinkler head at the facility, as it is important to keep all sprinklers free and clear for proper use .This training will be documented on a Staff Attendance Sheet and a copy sent to the Associate Executive Director to verity completion. A copy of this training will be maintained in the Emergency Preparedness Plan binder under the "training " section of the book.
On a weekly basis, the House Manager will monitor this process by touring the facility to maintain the protection of the sprinkler component. The House Manager will promptly remove any item(s) found hanging on a sprinkler head and addressed this concern immediately with staff through retraining and or corrective action.
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