Incomplete Fire Drill Documentation
Penalty
Summary
The facility failed to maintain complete documentation for fire drills conducted on every shift for each quarter, as required by NFPA 101. During a review of fire drill logs and interviews with the Administrator and Maintenance Supervisor, it was found that sign-in sheets for four out of twelve required fire drills were missing, specifically for the first quarter NOC shift, second quarter PM shift, and both PM and NOC shifts in the third quarter. The absence of these records was confirmed during the survey, and the Administrator acknowledged the missing documentation.
Plan Of Correction
K 712 Fire Drills Correct Deficient Practice: On 3/10/25, Director of Staff Development (DSD) called Southwest Fire Life Safety and Security LLC and scheduled fire drills for both the PM shift and NOC shifts on 03/26/25. Identify Others: DSD reviewed fire drills performed within the last 12 months, and no other deficient practice was found. Systemic Changes: In-service education was provided by the Administrator on 03/10/2025 to DSD and MS regarding the facility's policy and procedure titled "Fire and Life Safety Training Drills," indicating that fire and life safety drills are conducted on at least a monthly basis and at least quarterly on each shift. On 3/17/25, DSD called Southwest Fire Life Safety and Security LLC and created an annual schedule for the facility's fire drills. DSD will be in charge of ensuring these fire drills take place at least quarterly for each shift and will keep the written documentation of the quarterly fire drills conducted. Any deficient practice will be reported to the Administrator and corrected immediately. Monitoring: Completed fire drills will be reported monthly to the Safety Committee meeting by DSD until the Safety Committee has determined that compliance has been sustained. The facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/25