Failure to Conduct Fire Drills on a Random Basis
Penalty
Summary
The facility failed to conduct four out of twelve required fire drills on a random basis, as evidenced by documentation review and staff interviews. Specifically, observations showed that all first shift fire drills over the past twelve months were performed within the same hour each time (between 9:08 am and 10:03 am), rather than at varying times as required. During the exit conference, both the Administrator and Director of Maintenance confirmed that the fire drills were not performed randomly.
Plan Of Correction
A fire drill has been conducted for the first shift at 11:15 AM. Administrator to re-educate Maintenance Director on fire drills being held at random. Maintenance Director will continue to perform monthly fire drills on a random basis. NHA/designee will conduct audits weekly for 4 weeks and monthly for 2 months to ensure fire drills are being held randomly each month. Audits to be submitted to QAPI for review and recommendations.