Observations
Based on a review of the facility fire drill log and staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The facility fire drill log indicated fire drills were conducted in April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, and November 2025. However, staff interview confirmed that no fire alarm or smoke detector was set off during these fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ETHOS has revised its Fire Drill and Fire Safety Policy to explicitly require that all fire drills include activation of the fire alarm or smoke detector, unless activation is prohibited by the local fire authority (in which case written documentation and an alternative approved method will be used).
All staff in this office were notified re-educated on proper fire drill procedures, including:
Activation of the fire alarm system during drills
Required staff and resident response
Documentation requirements for fire drills
Fire drill documentation forms have been updated to include a required checkbox and narrative field confirming alarm activation during each drill.
The Director of Compliance will review fire drill documentation monthly for the next 12 months to ensure:
Fire drills are conducted as scheduled
Fire alarms or smoke detectors are activated
Documentation is complete and accurate
Any identified issues will be addressed immediately with corrective action and retraining as needed. |