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K0712
C

Failure to Conduct Required Fire Drills

Chambersburg, Pennsylvania Survey Completed on 04-16-2025

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 and perform fire drills as required, with deficiencies noted in the documentation review. Specifically, the facility did not perform fire drills for the 2nd shift in the 1st quarter of 2025, the 1st shift in the 3rd quarter of 2024, and the 3rd shift in the 3rd quarter of 2024. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director, who acknowledged that the fire drills were not conducted as mandated by the NFPA 101 standards, which require fire drills to be held at least quarterly on each shift under varying conditions.

Plan Of Correction

1 and 2. Maintenance Director will complete monthly fire drills, one per shift, per quarter. 3. Maintenance department will be educated on the standards of the facilities monthly fire drill policy ensuring they are being conducted one per shift, per quarter. 4. Maintenance or facility designee will audit facilities fire drills to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

See complete original report
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