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K0712
C

Failure to Conduct Required Fire Drills

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 conduct and perform fire drills as required by NFPA 101 standards. During a document review on October 8, 2024, it was revealed that the facility did not perform fire drills during the 2nd quarter on the 1st and 2nd shifts, the 3rd quarter on the 3rd shift, and the 4th quarter on the 2nd shift. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. A subsequent observation on December 9, 2024, confirmed that the issue had not been corrected, as verified by another interview with the Director of Maintenance.

Plan Of Correction

1. The facility is unable to retroactively ensure fire drills are completed in compliance with regulations. 2. Fire drills will be completed monthly in varying locations and varying shifts as per regulation. Quarterly audits will be completed to confirm drills are being conducted on the shifts for which they are scheduled. 3. Maintenance Director or Designee will conduct documentation audits to ensure compliance with regulation. Audit results will be presented to the QAPI Committee for review and analysis of need for ongoing monitoring.

See complete original report
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