Observations
Based on a review of fire drill records and staff interview on December 1, 2009, the facility failed to conduct a fire drill during sleeping hours at least every six months.
Findings:
Fire drill records were reviewed on December 1, 2009. The fire drill record documented that a fire drill was held during sleeping hours on November 6, 2009. A fire drill held during sleeping hours was not documented at any other time during the six months prior to November 6, 2009.
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Plan of Correction
The director of plant operations will meet and review the fire drill procedure and explain to his staff what the rule is for drills to be held during sleeping hours. The meeting will be held prior to Jan. 29, 2010. The Quality Administrator will track the drills and communicate to the plant operations director any issues. The director of plant operations director is in charge of compliance and will ensure that this is completed.
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