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K0346
F

Fire Alarm System Out of Service Without Proper Protocols

Flourtown, Pennsylvania Survey Completed on 05-01-2025

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 meet the requirements of NFPA 101 regarding the fire alarm system. Specifically, the fire alarm system was out of service for more than four hours within a 24-hour period. During this time, the facility did not notify the authority having jurisdiction, nor did they evacuate the building or provide an approved fire watch for the safety of all parties left unprotected by the shutdown. This deficiency was identified based on document review and interviews, indicating a lack of required policies affecting the entire facility.

Plan Of Correction

Facility will maintain a fire watch policy and update in EP book. The Director of Maintenance will audit EP book for updated policies 2x weekly for 2 months. All findings will be brought to QAPI for review.

See complete original report
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