Failure to Conduct Required Fire Drills
Penalty
Summary
Snyder Memorial Health Care Center was found to be non-compliant with the Life Safety Code requirements for an existing health care occupancy during an Abbreviated Survey conducted as part of a Complaint Investigation. The facility, a one-story, Type V (111), protected, wood frame building that is fully sprinklered, failed to conduct the required fire drills. Document review revealed that the facility did not perform 12 out of 12 required fire drills, as there was no documentation of the sending/receiving of a fire alarm signal or the simulation of emergency fire conditions. Additionally, the facility conducted silent drills outside the defined NFPA time intervals, specifically between 9:00 p.m. and 6:00 a.m. An interview with the maintenance supervisor confirmed these deficiencies.
Plan Of Correction
A fire drill was immediately held in the facility on 1/8/2025 at 1400 during the 1st shift. A test of the pull station was completed and documentation of successful check obtained. The Director of Maintenance was educated by the facility Administrator on the requirements of conducting fire drills and maintaining documentation of fire drills in accordance with NFPA 101. An all staff education on fire prevention policy will be completed by January 31, 2025. The education will be conducted by the facility administrator designee. A calendar of scheduled fire drills has been completed for the calendar year and shared only by the Director of Maintenance and the facility administrator to facilitate unexpected times and varying conditions. The facility Director of Maintenance will be responsible for performing the fire drills in accordance with requirement. The Facility Administrator will audit fire drills monthly to ensure completion and compliance with the requirement. The results of the audit and the fire drill will be reviewed by the facility Quality Assurance and Performance Improvement Committee at a minimum of the next 3 scheduled meetings.