Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct the required fire drills as mandated by NFPA 101 standards, which necessitate fire drills to be held at least quarterly on each shift. The documentation review revealed that the facility did not have records for fire drills for the first shift and second shift of the first quarter, as well as for all three shifts during the second, third, and fourth quarters of the year. This indicates that eleven out of the twelve required fire drills were not documented, affecting the entire facility. An interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation for the fire drills that were supposed to be conducted over the previous twelve months. This lack of documentation suggests that the facility did not adhere to the established routine of conducting fire drills at expected and unexpected times under varying conditions, as required by the NFPA 101 standards.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff/Designee on the fire drill policy. Fire drills will be conducted monthly by the Maintenance Director/Designee at varying times to ensure that each shift has a fire drill quarterly. NHA will audit the fire drills monthly x 3 months.