Inadequate Fire Drill Procedures
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Sections 19.7.1.4 through 19.7.1.7. This deficiency was identified during a document review and interview on December 3, 2024, in the presence of the U.S. FOIA (b)(6). The review revealed that the facility's fire drill reports did not specify the method used for the simulation of alarm transmission signals. Additionally, six out of twelve drills were conducted on a Saturday, and the times for the first shift drills were not varied, which is a requirement for ensuring staff preparedness under different conditions. The lack of specificity in the fire drill reports and the failure to vary drill times and activation types had the potential to affect all residents in the facility. The findings were verified by the [R] at the time of the record review, and the U.S. FOIA (b)(6) confirmed the inadequacies in the documentation and execution of the fire drills. These issues were discussed at the Life Safety Code exit conference on December 4, 2024.
Plan Of Correction
Plan of Correction K0712 Level F Completion Date: 1/15/2025 Corrective Action: - Additional 12/24 Fire Drill will be performed during the day shift and not on a weekend. - Additional 12/24 Fire Drill will reflect type of signal. ID Other Residents: - All residents within the facility have the potential to be affected. Systemic Change: - In-service Fire Drill Testing, Scheduling, Monitoring to the Maintenance Department by the Maintenance Director on 2/2/24. - Fire Drills will be performed during the evening and night shifts and not on the weekend to ensure fire drill training is completed on all shifts. - Supervision log will be utilized to ensure fire drills are completed timely, note signal type and vary for the appropriate shift and time. Monitoring: - Audit - Fire Drill will be completed on the following schedule: (3) quarterly x 3 quarters by the Maintenance Director/Designee. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.