Failure to Conduct Required Fire Drills Per Shift Per Quarter
Summary
During a Life Safety Code survey, it was found that the facility failed to conduct fire drills at least once per shift per quarter, as required by their policy. The policy, titled Fire Safety Training Program, mandates twelve fire drills annually, with each shift conducting a drill every quarter. However, a review of the fire drill report binder revealed that in the first quarter of 2024, only two drills were conducted, one on the third shift and one on the first shift. In the second quarter, three drills were conducted, but two were on the third shift and one on the first shift, with no drills on the second shift. In the third quarter, three drills were conducted, two on the second shift and one on the first shift, again missing the third shift. The Administrator, during an interview, stated that the Maintenance Director was responsible for scheduling and performing fire drills. However, the facility had been without a Maintenance Director since the previous week, and the former Maintenance Director had reported completed fire drills at the facility's monthly quality assurance meetings without indicating any missed drills. The Administrator expected all fire drills to be documented, and the Trainer mentioned in the policy referred to the Maintenance Director. This deficiency affected both resident use floors of the facility.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: No residents were identified as being affected by this deficiency. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: Director of Facilities or Designee to in-service all maintenance staff on the minimum requirement to conduct one fire drill, per shift, per quarter. Director of Maintenance to review the policy and procedure titled Fire Safety Training Program. Maintenance to conduct 2 fire drills monthly for the first 4 months on alternating shifts to ensure that the minimum requirement of one fire drill on every shift per quarter takes place. All drills will be planned 4 months in advance by the Director of Maintenance to ensure drills will be done on the appropriate shift. Monitor Corrective Actions: The Director of Facilities or Designee will review all completed fire drills monthly and report all findings to the Administrator and the QAPI Committee monthly. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan.
Penalty
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