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K0345
C

Failure to Document Annual Fire Alarm System Testing

Gettysburg, Pennsylvania Survey Completed on 02-04-2025

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 verifying that the annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on February 4, 2025, between 9:30 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 2:00 PM, both the Administrator and Maintenance Director confirmed the lack of documentation for the required annual testing and inspection.

Plan Of Correction

Annual inspection completed on March 15, 2024. Fire alarm system will be inspected annually going forward. Maintenance staff will be educated on having the fire alarm system inspected annually. Fire alarm system audit will be completed semi-annually to be sure that the fire inspections are occurring and results reported at the next QAPI meeting.

See complete original report
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