Fire Drill Record Alterations
Penalty
Summary
The facility failed to conduct fire drills as required by NFPA 101, which mandates that fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. These drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. During a review of the facility's fire drill records, it was found that the sign-in sheets for the drills did not have matching dates, and some dates were altered. Specifically, the fire drills dated 8/14/24 and 7/25/24 had matching sign-in sheets, but the dates were changed. Similarly, the drills on 11/29/24 and 10/31/24 had matching sign-in sheets, but the dates were removed from the sheets. The Maintenance Director, who had recently started working at the facility, stated that he did not conduct the drills prior to the survey. The Administrator, upon reviewing the drills, acknowledged the visible alterations in the records and indicated that further investigation would be conducted. This deficiency could result in staff not being prepared to address and respond to a fire emergency, thereby endangering the occupants of the building.
Plan Of Correction
K712 Fire Drills 1. Fire Drills are current and up to date. 2. Audit was completed on fire drills; any abnormal finding was noted. 3. A. Fire Drill will be conducted monthly. B. Staff educated on fire drills. 4. Administrator will audit monthly to ensure fire drills are completed, and findings will be brought to QA.