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K0521
F

Failure to Inspect HVAC Fire/Smoke Dampers

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 and inspect its HVAC systems, specifically the fire/smoke dampers, affecting the entire facility. During a document review on January 21, 2025, it was found that the facility could not provide documentation of a fire/smoke dampers inspection performed within the past four years. This deficiency was confirmed during an exit interview with the Executive Director of Construction and Ancillary Services on the same day.

Plan Of Correction

ED of construction to Inservice supervisor of Plants Operations on policy and procedure on smoke dampers. Damper inspection was completed by facility on 11-06-2024. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.

See complete original report
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