Missed Fire Drills on Second Floor
Penalty
Summary
During a Life Safety Code survey, it was found that fire drills were not conducted at least once per shift per quarter on the second floor of the resident unit. The facility's policy, dated 2010, requires fire drills to be conducted once per shift, per quarter at varying times. However, a review of fire drill reports from 2024 revealed that no fire drills were conducted during the fourth quarter. The Facilities Supervisor admitted that although fire drills were scheduled, they were not conducted due to an oversight. The Director of Facilities confirmed that both they and the Facilities Supervisor were responsible for planning and conducting the drills, and acknowledged the oversight. The Administrator stated they were unaware of the missed drills until the survey and did not typically review the fire drill schedule with the Director of Facilities or the Facilities Supervisor.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 K712 Fire Drills 1. The Facility will ensure fire drills are conducted in accordance with NFPA 101. 2. The Director of Facilities and Facilities Supervisor reviewed and revised the policy entitled Conducting Fire Drills. Inservice with Maintenance staff conducted reviewing policy and future schedule. The 2025 fire drill schedule was reviewed to ensure drills are planned for once on each shift per quarter. 3. The Director of Facilities will audit fire drills to ensure they are conducted once on each shift per quarter. 4. Fire drill audit will continue for 12 months and be brought to QA/QAPI meetings on a quarterly basis for review and need for continuance. 5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities.