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 - Component: 01 - Tag: 0712
Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.
Findings include:
1. Review of documentation on January 17, 2024, between 9:45 AM and 11:00 AM, revealed the facility did not perform fire drills every quarter, for the following shifts:
a. 2nd quarter 2023, 3rd shift; b. 3rd quarter 2023, 3rd shift; c. 4th quarter 2023, 3rd shift.
Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the fire drills were not performed.
| | Plan of Correction - To be completed: 01/18/2024
On 1/17/24, it was determined that the facility failed to conduct and perform fire drills (one per shift, per quarter) affecting Component 01.
On 1/18/2024, the Facility Systems Specialist whom is responsible for Fire Drill implementation for the facility was made aware of the deficiency. A meeting took place between the Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services upon where the Facility Systems Specialist responsible for Fire Drills was re-educated on NFPA Standard 19.7.1.4 through 19.7.1.7, specifically the need for 3rd shift drills once per quarter.
On 1/18/2024, the Facility Services Specialist updated internal documentation to ensure that such drills would be accomplished, citing the need for one 3rd shift drill per quarter.
In addition, an annual Fire Drill work order (S.W.O. #5840) was created and assigned to Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services to solicit an annual plan and schedule of fire drill dates.
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