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K0293
C

Failure to Document Monthly Exit Sign Inspections

Pottstown, Pennsylvania Survey Completed on 12-09-2024

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 provide documentation of monthly exit sign inspections, which is a requirement under NFPA 101 for exit signage. During a document review on October 8, 2024, it was found that the facility did not have records verifying that exit signs were visually inspected over the past twelve months. This deficiency was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of the required documentation. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, as the facility still lacked the necessary documentation. The Director of Maintenance confirmed during an interview on the same day that the deficiency remained unaddressed.

Plan Of Correction

1. The facility is unable to retroactively document visual inspection of exit signs. 2. Facility-wide audit of all exit signs completed. 3. Audits of exit signs will be conducted monthly. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.

See complete original report
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