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K0712
C

Failure to Conduct Fire Drills at Varying Times

Exeter, Pennsylvania Survey Completed on 12-10-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper fire drill procedures, as evidenced by the documentation review and interview. Specifically, it was observed that ten out of the twelve required fire drills were conducted within one week of each other, which does not meet the requirement of holding fire drills at varying times and conditions. This deficiency affected both floors of the facility. During the exit interview, the Facility Administrator, Facilities Manager, and Regional Facilities Manager confirmed the fire drill deficiencies.

Plan Of Correction

- Unable to correct the 10 out of 12 fire drills conducted within 1 week of one another. - Fire drills will be conducted on different days and times throughout the year. NHA will educate Maintenance Director/designee to ensure fire drills are conducted at least quarterly on each shift on different days and times throughout the year. - Fire drills will be audited monthly x3 by Maintenance Director/designee to ensure drills are completed at least quarterly on each shift on different days and times throughout the year. Trends will be reviewed at QAPI meeting monthly.

See complete original report
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