Failure to Document Quarterly Fire Drill
Penalty
Summary
The facility failed to perform fire drills in accordance with NFPA 101 standards, as evidenced by a lack of documentation for one of the four required fire drills in 2024. Specifically, the missing documentation pertained to the fire drill that was supposed to be conducted during the third quarter on the second shift. This deficiency was identified during a records review process conducted between noon on April 7, 2025, and 5:00 pm on April 8, 2025, with the Maintenance Director present. During the staff interview conducted within the same timeframe, the Maintenance Director acknowledged the absence of documentation for the fire drill. This finding was also discussed and acknowledged by the Administrator during the exit conference. The report highlights that the facility did not meet the requirement of conducting fire drills at least quarterly on each shift, as mandated by NFPA 101.
Plan Of Correction
5/16/25 Immediate Action: A fire drill was conducted on the missed shift on May 9, 2025 to ensure that staff on the second shift are trained and prepared for emergency situations. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: A fire drill schedule/calendar was created for the entire year which clearly indicates the required monthly drill shift. Monitoring: The Director of Maintenance will ensure the facility documentation is accurate regarding the scheduled shift. The schedule/calendar will be submitted to the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: The Director of Maintenance