Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct one of the twelve required fire drills, specifically missing a third shift fire drill in the first quarter of 2024. This deficiency was identified during a documentation review on January 7, 2025, at 8:30 a.m., which revealed the absence of documentation for the required drill. An interview with the Facility Administrator and Maintenance Director confirmed the lack of documentation for a fire drill conducted between January and March 2024, affecting the entire facility.
Plan Of Correction
The facility is unable to make up the missed drill. No other discrepancies were noted for other drills conducted during 2024. A schedule for 2025 fire drills was developed and meets the requirements of K 0761. Maintenance staff were educated on K 0761. The Executive Director will audit fire drills monthly for one quarter. Results will be reviewed at the Quality Assurance Performance Improvement meeting.