Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct five out of the twelve required fire drills over a twelve-month period, affecting the entire facility. Specifically, there was no documentation for a fire drill conducted in the second quarter for the third shift, and for the first, second, and third shifts in the third quarter, as well as the third shift in the fourth quarter. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the lack of documentation for these fire drills.
Plan Of Correction
1. Facility cannot retroact fire drills from those that were missing from the second quarter of the year for third shift, the first, second and third shifts in the third quarter and the third shift in the fourth quarter. 2. Facility will create a yearly plan for fire drills for every shift for every quarter. 3. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure all fire drills are being conducted. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.