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K0712
E

Failure to Document Fire Drills

Philadelphia, Pennsylvania Survey Completed on 12-23-2024

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 properly document required fire drills, affecting three of twelve shifts. During a document review on December 23, 2024, it was revealed that the facility did not document fire drills for the 2nd quarter, 3rd shift, and the 4th quarter, 1st and 2nd shifts. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day.

Plan Of Correction

Fire drills will be conducted monthly for all three shifts quarterly. Maintenance Dir/designee will re-educate maintenance staff on conducting fire drills on every shift quarterly. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

See complete original report
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