Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 30, 2024, at Beacon Light Adult Residential Services, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID 440211
Component 01
Cottage 01
Based on a Medicaid Recertification Survey completed on May 30, 2024, it was determined that Beacon Light Adult Residential Services 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, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 Component - 01
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 30, 2024, at 12:50 a.m., revealed the facility could not provide documentation that a fire alarm semi-annual visual inspection had been performed.
Interview with the director of maintenance on May 30, 2024, at 12:50 a.m., confirmed the documentation was unavailable.
Plan of Correction:A fire alarm semi-annual visual inspection occurred for all three cottages on 6/4/24.
Moving forward all three cottages will have a semi-annual visual inspection of the fire alarm system each January and July. The Executive Director directed the maintenance department of this new process on 5/3024.
To monitor and prevent this issue from occurring in the future, this area will be revised on the "Monthly Review of Life Safety" form to include the stipulated January and July months to complete the fire alarm semi-annual visual inspection. The maintenance department conducts their life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. The Director of Facility Management is responsible for monitoring this area.
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID 440211
Component 02
Cottage 02
Based on a Medicaid Recertification Survey completed on May 30, 2024, it was determined that Beacon Light Adult Residential Services 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, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - BUILDING 02 Component - 02
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 30, 2024, at 12:50 a.m., revealed the facility could not provide documentation that a fire alarm semi-annual visual inspection had been performed.
Interview with the director of maintenance on May 30, 2024, at 12:50 a.m., confirmed the documentation was unavailable.
Plan of Correction:A fire alarm semi-annual visual inspection occurred for all three cottages on 6/4/24.
Moving forward all three cottages will have a semi-annual visual inspection of the fire alarm system each January and July. The Executive Director directed the maintenance department of this new process on 5/3024.
To monitor and prevent this issue from occurring in the future, this area will be revised on the "Monthly Review of Life Safety" form to include the stipulated January and July months to complete the fire alarm semi-annual visual inspection. The maintenance department conducts their life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. The Director of Facility Management is responsible for monitoring this area.
NFPA 101 STANDARD
Fire Drills
Name - BUILDING 02 Component - 02
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, the facility failed to perform required fire drills, affecting one of three building components.
Findings include:
Document review on May 30, 2024, at 12:35 p.m., revealed the facility lacked documentation for a fourth quarter, first shift fire drill for cottage #2.
Interview with the executive director on May 30, 2024, at 12:35 p.m., confirmed the facility lacked the fire drill documentation.
Plan of Correction:The Executive Director will review the current 2024 fire drill schedule to assure that each of the cottages run at least one fire drill per shift per quarter. This review will be completed by 6/15/24. Additionally, a grid sheet will be developed which depicts compliance in this area which shows each fire drill per shift, per quarter. This will also be completed by 6/15/24.
The Executive Director is responsible for compliance in this area and for maintaining the schedule and accompanying grid which graphically depicts the fire drill schedules for each cottage.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID 44021100
Component 03
Cottage 3
Based on a Medicaid Recertification Survey completed on May 30, 2024, it was determined that Beacon Light Adult Residential Services 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 not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - BUILDING 03 Component - 03
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review, observation, and interview, the facility failed to maintain general requirements of the life safety code that are not addressed by specific K-tags, but are still deficient, in one of three building components.
Findings include:
Document review on May 30, 2024, at 1:00 p.m., revealed the facility failed to obtain Department of Health State Plan Review approval and a granted occupancy from the Life Safety Division for the renovation of the bathroom in cottage #3.
Interview with the director of maintenance on May 30, 2024, at 1:00 p.m., confirmed the facility could not provide approval documentation for the renovation project.
Plan of Correction:The Director of Facility Management is still looking for the Department of Health plan review approval documentation for the renovation of the bathroom in Cottage 3. If he cannot locate the documentation by 6/7/24, he will resubmit the application.
Moving forward prior to any construction or renovation the required paperwork will be obtained prior to any work be initiated. Additionally, the Director of Facility Management will provide the Executive Director a copy of the required documentation to be stored in his office as well.
The Director of Facility Management will be responsible for this area and for obtaining all regulatory documentation before construction/renovation work is initiated.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - BUILDING 03 Component - 03
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:
Document review on May 30, 2024, at 12:50 a.m., revealed the facility could not provide documentation that a fire alarm semi-annual visual inspection had been performed.
Interview with the director of maintenance on May 30, 2024, at 12:50 a.m., confirmed the documentation was unavailable.
Plan of Correction:A fire alarm semi-annual visual inspection occurred for all three cottages on 6/4/24.
Moving forward all three cottages will have a semi-annual visual inspection of the fire alarm system each January and July. The Executive Director directed the maintenance department of this new process on 5/3024.
To monitor and prevent this issue from occurring in the future, this area will be revised on the "Monthly Review of Life Safety" form to include the stipulated January and July months to complete the fire alarm semi-annual visual inspection. The maintenance department conducts their life safety checks each month. All monthly checks are documented on "Monthly Review of Life Safety" sheets which are reviewed and maintained in the Executive Director's office. The Director of Facility Management is responsible for monitoring this area.
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