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K0100
C

Deficiency in Providing Accurate Floor Plans

Philadelphia, Pennsylvania Survey Completed on 01-23-2025

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 was found deficient in providing accurate, portable floor plans as required by the Life Safety Code. During a document review on January 23, 2025, it was discovered that the facility did not have a set of accurate, portable floor plans available on site. This deficiency affects the entire facility and is a requirement by the Division of Safety Inspection for use during the Life Safety Code Survey. The necessary floor plans should include details such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. An exit interview with the Administrator and Maintenance Director confirmed the absence of these accurate floor plans.

Plan Of Correction

1. The floor plans were accurately revised to include the following, but not limited to smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. 2. NHA/designee will educate maintenance on the requirements for having portable, accurate floor plans on site. NHA/designee will also conduct a house-wide education to ensure staff is aware of up-to-date floor plans. 3. NHA/designee will audit accuracy of floor plans monthly x3. Results of the audit to be reported monthly QA.

See complete original report
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