Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 24, 2023, 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 24, 2023, 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 construction, which is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Fire Drills
Name - MAIN BUILDING 01 (IMPRACTICAL) Component - 01
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, it was determined the facility failed to perform one of twelve required fire drills.
Findings include:
1. Document review on May 24, 2023, at 9:00 am, revealed the facility could not provide documentation that a fire drill had been conducted on the 1st shift, for the 3rd quarter of 2022.
Interview with the Administrator and Maintenance Manager on May 24, 2023, at 10:15 am, confirmed the missing documentation.
Plan of Correction:C1
The ICF Director updated the fire/evacuation drill schedule on May 16, 2023. Starting June 1, 2023 fire/evacuation drills will occur monthly, and will vary in time and across all three shifts.
C2
The ICF Director updated the fire/evacuation drill schedule on May 16, 2023. Starting June 1, 2023 fire/evacuation drills will occur monthly, and will vary in time and across all three shifts.
C3:
The ICF Director will review fire/evacuation drill binder monthly and will ensure any outstanding drills are completed immediately. The ICF Director will communicate concerns to the IDD-Division Director, and Senior Director of Quality Improvement.
C4:
COMHAR's Quality Management Department will do monthly audits of the fire/evacuation drill binder for the following three months and report on finding to the ICF Director, IDD-Division Director and Chief Program Officer for a required plan of correction of areas of non-compliance. Based on the improvements of the fire/evacuation binder, the Quality Management Department will move to quarterly review of binder thereafter.
C5:
The IDD-Division Director and Senior Director of Quality are responsible for execution and tracking of activity completion for this citation. Areas of non-compliance will be addressed with the responsible staff member accordingly and up to and including progressive discipline if appropriate.
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