Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform required fire drills, which are essential for ensuring staff readiness in case of a fire emergency. Specifically, the facility did not perform fire drills for all three shifts during the second quarter of 2024. This deficiency was identified through a review of documentation and confirmed during an interview with the Administrator and Maintenance Director. The absence of these drills affects the entire component of the facility, as fire drills are crucial for familiarizing staff with emergency procedures and ensuring they are prepared for unexpected fire conditions.
Plan Of Correction
Fire drills will be performed, one per shift, per quarter. Maintenance staff will be educated on completing fire drills on one shift per quarter. An audit will occur quarterly to ensure fire drills will be performed one per shift, per quarter. Audit results will be reported to QAPI.