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K0346
F

Missing Fire Watch Policy During Fire Alarm Outage

Philadelphia, Pennsylvania Survey Completed on 06-30-2025

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 required policies for the fire alarm system, specifically lacking a fire watch policy to implement in the event the fire alarm system was out of service for more than four hours in a 24-hour period. During a document review, it was found that there was no such policy available, which is necessary to ensure safety when the fire alarm system is not operational. This finding was confirmed during an interview with the Maintenance Supervisor and Director of Safety/Security.

Plan Of Correction

Fire watch policy in place. Facility will ensure policy is available for survey team during all inspections.

See complete original report
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