Failure to Conduct and Document Fire Drills
Penalty
Summary
The facility failed to conduct and properly document required fire drills, affecting three of twelve quarters. During a document review on January 30, 2025, it was revealed that the facility did not provide documentation of fire drills for the 1st quarter of 2024 across all three shifts. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day.
Plan Of Correction
Step 1 Moving forward, the facility will ensure that fire drills are completed quarterly on each shift. Step 2 The maintenance director was educated on the requirement to conduct quarterly fire drills on each shift. Step 3 The maintenance director/designee will audit fire drill documentation monthly x 4 to ensure that fire drills are completed as required. Findings will be reported in QAPI meeting.