Failure to Document Required Fire Drills
Penalty
Summary
The facility failed to meet the National Fire Protection Association (NFPA) 101 fire drill requirements, as evidenced by the absence of documentation for seven out of twelve required fire drills. During a document review and interview conducted on January 23, 2025, it was revealed that the facility did not provide documentation for fire drills on the first shift of the first quarter, the first and second shifts of the second quarter, the third shift of the second quarter, the third shift of the third quarter, and the second and third shifts of the fourth quarter. The maintenance supervisor confirmed the lack of documentation during the survey.
Plan Of Correction
A quarterly fire drill was conducted February 3, 2025 on first shift. Second and third shift drills will be conducted no later than February 27, 2025. The Maintenance Director was educated on January 24, 2025 by the Administrator regarding the requirement that quarterly fire drills must be completed on each shift. A monthly audit will be conducted for 4 months by the Maintenance Director to ensure that quarterly fire drills are completed on each shift and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.