Failure to Conduct and Document Fire Drills for Second Shift
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was found that the facility failed to ensure fire drills were properly performed for one of the three staff work shifts. Specifically, the facility did not conduct a fire drill for the second shift (2:00 PM to 10:00 PM) during the fourth quarter of 2024. The fire drill reports for the fourth quarter listed drills conducted on October 31 at 8:43 AM, November 1 at 9:30 AM, and December 27 at 4:00 AM, none of which covered the second shift. Additionally, the fire drill report dated November 1, 2024, lacked staff signatures or documentation of staff participation, with the attendance section left blank. The Environmental Services Director admitted to not using a schedule for fire drills and acknowledged the oversight in conducting the second shift drill and obtaining staff signatures.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K712 Corrective Action- To ensure that the facility meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Drills. 1. On 3/6/25 a 2nd shift fire drill was performed to compensate for the missed second shift fire drill from the fourth quarter of Calendar Year 2024. 2. The Maintenance Director will complete an audit of fire drills for Calendar Year 2025, to ensure fire drills are properly documented (including sign in sheets) and performed on each shift as required by The Life Safety Code of the NFPA. 3. The Administrator will oversee in-services to all maintenance department staff in regards the importance maintaining compliance with the NFPA Fire Drill requirements. 4. To prevent future deficit in this practice, the Maintenance director / designee will perform 1 audit per month for 3 months to ensure fire drills have been performed and documented quarterly on each of 3 shifts. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K712.