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K0345
F

Fire Alarm System Maintenance Deficiency

Philadelphia, Pennsylvania Survey Completed on 01-21-2025

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 maintain its fire alarm system in proper operating condition, which affected the entire facility. During an observation on January 21, 2025, at 10:45 a.m., it was noted that the fire alarm panel displayed multiple trouble codes. This issue was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day at 1:15 p.m.

Plan Of Correction

ED of construction to in-service the Maintenance staff of proper reading of the fire panel and report any trouble alarms immediately to their Supervisor. The Facility is working with the current Vendor (Johnson Controls) and an additional Vendor (Independence) to make repairs or replace the aged fire panel so trouble alarms stop randomly reporting. Due to the difficulty of parts or replacement of the fire panel, the Facility is requesting a 120-day time-limited waiver. The fire panel will be audited daily with a record of any current trouble signals recorded until repairs are completed. TLW request sent via email. Johnson Control letter sent to center and forwarded to DOH stating that they estimate that work can be completed 90 days from March 7th 2025 which June 5th 2025. If further extension is required center will update doh with further correspondence from Johnson Controls.

See complete original report
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