Missing Attendance Sheets for Fire Drills
Penalty
Summary
The facility failed to ensure that fire drills were conducted under varied conditions as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the fire drill logs for the fourth quarter of 2024 were missing attendance sheets for the Day, Evening, and Night shifts. This omission made it impossible to verify staff participation in the drills. The Director of Maintenance confirmed in an interview that the fire drills are conducted by an outside vendor and acknowledged the absence of the attendance sheets.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K712 Completion Date: (No later than 60 days from exit date 03/20/2025) (05/19/2025). I. Immediate Corrective Action: 1. Fire Drill Attendance Sheets for Fourth Quarter of 2024: - On 3/20/25, the Director of Maintenance contacted the outside vendor responsible for conducting the fire drills to request the missing attendance sheets for the Day, Evening, and Night shifts from the fourth quarter of 2024. - The vendor provided the missing attendance sheets on 3/20/25, which were then added to the facility's fire drill records for the appropriate quarter. 2. Fire Drill Documentation Review: - The Director of Maintenance immediately reviewed the fire drill documentation for all prior quarters to ensure that attendance sheets for all shifts were present and complete. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of the fire drill logs for the entire year 2024 to ensure that all attendance sheets were accounted for. III. Systemic Changes: 1. An in-service was conducted by the Director of Maintenance for all maintenance staff on the importance of verifying and maintaining complete fire drill records, including attendance sheets. - A reminder was also issued to the outside vendor to ensure that all necessary documentation is submitted following each drill. IV. Quality Assurance: 1. The Director of Maintenance established a monthly internal audit to ensure that fire drill logs, including attendance sheets, are complete and accurate. - The audit will be conducted monthly for six months, and findings will be reviewed to ensure full compliance with NFPA 101. 2. The results of the audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance