Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct two out of twelve required fire drills, specifically missing the 3rd shift drills for the 3rd and 4th quarters of 2024. This deficiency was identified during a documentation review and interview process. The absence of documentation for these fire drills was observed on January 22, 2025, at 9:40 a.m., and was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day at 12:30 p.m. This failure affected both floors of the facility, indicating a lapse in compliance with the NFPA 101 fire drill requirements, which mandate quarterly drills on each shift under varying conditions.
Plan Of Correction
1. NHA and Maintenance Director could not retroactively complete the missed annual fire drills. 2. NHA and the Director of Maintenance were re-educated on the importance of completing scheduled annual fire drills. 3. NHA and the Maintenance Director created a new schedule for fire drills to ensure they happen monthly on each shift (12 per year). 4. NHA will perform monthly audits to ensure one fire drill was performed that month.