Name: MAIN BUILDING - Component: 01 - Tag: 0712
Based on document review and interview, it was determined the facility failed to perform fire drills, as required for the component.
1. Review of documentation on February 5, 2019, between 10:15 AM and 11:15 AM revealed the facility did not perform required fire drill, during the 3rd Quarter.
Interview with the Center Director on February 5, 2019, at 11:15 AM confirmed the 3rd Quarter fire drill was not conducted.
| ||Plan of Correction - To be completed: 02/18/2019|
0712 NFPA 101 STANDARD FIRE DRILLS
PLAN OF CORRECTION:
Fire drills will be held at unexpected times under varying conditions, at least quarterly on each shift and include transmission of the fire alarm and participation from all staff in attendance.
The Center Leader will establish a schedule for all quarterly fire drills in the Leadership calendar and ensure fire drills are performed each quarter.
Fire drills will be documented on the `Fire Drill Report' and include all present teammates. An evaluation will completed to determine if any change in the procedure is needed. .
RESPONSIBLE PARTY AND MONITORING:
The Center Leader is responsible for ensuring the occurrence of quarterly fire drills. The Center Leader or designee will review each completed fire drill report to ensure fire drills are occurring each quarter and times of occurrences remain varied from quarter to quarter. Fire Drill reports will be maintained the Environment of Care notebook behind the Fire Drill tab for ease in locating and tracking for quarterly occurrences. The Center Leader will provide the report and the evaluation of the drill to the QAPI Committee quarterly for review and recommendations. Recommendations will be submitted to the Governing Body for review and approval.
COMPLETION DATE: 2/18/2019