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K0712
E

Failure to Conduct Quarterly Fire Drills on 2nd Shift

Harrisburg, Pennsylvania Survey Completed on 03-13-2025

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 conduct fire drills on the 2nd shift every quarter, which affects the entire component. Upon reviewing documentation on March 13, 2025, it was revealed that the facility did not perform fire drills for the 2nd shift during several quarters in 2024. Specifically, fire drills were not conducted for the 1st quarter on the 3rd shift, the 2nd quarter on the 1st, 2nd, and 3rd shifts, the 3rd quarter on the 1st, 2nd, and 3rd shifts, and the 4th quarter on the 3rd shift. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the time of the exit conference.

Plan Of Correction

The facility will conduct a fire drill on 2nd shift on March 31, 2025. Fire drills will be performed on each shift quarterly. The Maintenance Director was re-educated on the need to have a fire drill on each shift quarterly. The Safety Committee will develop a schedule of monthly fire drills and audit quarterly for completion.

See complete original report
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