Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101 standards, as evidenced by the absence of documentation for required fire drills. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of one of the three required fire drills during the third quarter of 2024 for the second shift. Additionally, there was no evidence of two of the three required fire drills during the fourth quarter of 2024 for the first and third shifts. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were further discussed with the Administrator during the exit conference. The lack of documentation for these fire drills indicates a failure to comply with the established routine of conducting fire drills at unexpected times under varying conditions, as required by NFPA 101.
Plan Of Correction
1. The Maintenance Director in charge of oversight of fire drills in 2024 is no longer with the facility. A fire drill was conducted on each shift of the three shifts during the first quarter of 2025 by the new Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the new Maintenance Director by NHA on 4/17/2025 on the requirement to conduct fire drills in accordance with NFPA 101. Monthly audits will be conducted by the Maintenance Director or designee to ensure fire drills are conducted on each of the three shifts monthly. 4. Results from the fire drills will be reported to and reviewed by the QA&A committee.