QA Investigation Results

Pennsylvania Department of Health
COMHAR ALLEGHENY
Building Inspection Results

COMHAR ALLEGHENY
Building Inspection Results For:


There are  29 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on May 7, 2024, at Comhar Allegheny, 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 (IMPRACTICAL) Component - 01

Facility ID# 55741100
Component 01

Based on a Medicaid Recertification Survey completed on May 7, 2024, it was determined that Comhar Allegheny 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 (111), protected wood frame building, that is fully sprinklered.

State plans approved as Impractical.




Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - MAIN BUILDING 01 (IMPRACTICAL) 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, it was determined the facility failed to perform smoke detection sensitivity testing, affecting the entire facility.

Findings include:

Document review on May 7, 2024, at 8:30 a.m., revealed the facility could not provide smoke detector sensitivity documentation at the time of survey.

Interview with the Administrator and Maintenance Manager on May 7, 2024, at 10:45 a.m., confirmed the missing documentation.







Plan of Correction:

C1:
Smoke Detector Sensitivity testing for the Intermediate Care Facility program (ICF) located on 129 W. Allegheny Avenue were completed on 05/12/2021 and on 09/20/2023. COMHAR Facilities Office Manager emailed Emergency Response Alarm, the company who completed the test on 05/17/2024 to obtain the Smoke Detector Sensitivity Report. Company representative forwarded the Smoke Detector Sensitivity Report to COMHAR Facility Office Manager on 05/20/2024.
C2:
Smoke Detector Sensitivity testing for the Intermediate Care Facility program (ICF) located on 129 W. Allegheny Avenue were completed on 05/12/2021 and on 09/20/2023. COMHAR Facilities Office Manager emailed Emergency Response Alarm, the company who completed the test on 05/17/2024 to obtain the Smoke Detector Sensitivity Report. Company representative forwarded the Smoke Detector Sensitivity Report to COMHAR Facility Office Manager on 05/20/2024.
C3:
For future testing, the COMHAR Facility Office Manager will email the Emergency Response Alarm company representative within 2 weeks of smoke detector sensitivity testing completion to obtain the report.
C4
The Senior Director of Quality Improvement or Quality Improvement designee will review for compliance utilizing the IFC Utilization Review Tool during their scheduled Utilization Review on 08/06/2024 and during ongoing scheduled utilization reviews. The Senior Director of Quality Improvement or Quality Improvement designee will email all review finding within one week of the review.
C5
The Chief Information Officer is responsible for execution and tracking of activity completion for this citation. Within one week of discovery, the Chief Information Officer will communicate any areas of non-compliance and follow up steps taken to the team via email, including the IDD-Division Director, Senior Director of Quality Improvement, the Qualified Intellectual Disabilities Professional (QIDP) and the COMHAR Facilities Office Manager.