Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712
Based on observation and interview, it was determined the facility failed to maintain fire drills in nine of twelve instances, affecting two of two floors.
Findings include:
1. Observation on May 1, 2025, at 12:20 p.m., revealed nine of twelve required fire drills were performed during the last week of each month during the previous twelve month period (between the 24th and 31st of each affected fire drill).
Exit interview on May 1, 2025, between 12:35 p.m., and 12:40 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire drill deficiencies.
| | Plan of Correction - To be completed: 05/14/2025
1. The projected schedule for fire drills has been updated to ensure they are being held at expected and unexpected times under varying conditions, at least quarterly on each shift.
2. Maintenance Director/Designee will conduct weekly random audits for 4 weeks to ensure that fire drills are being held at expected and unexpected times under varying conditions, at least quarterly on each shift. Findings of the audits will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for further action planning if required.
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