Observations
Based on a review of fire drill records and an interview with the project/facility director, the facility failed to conduct a fire drill during sleeping hours at least every six months, as required.
The findings include:
Fire drill records from July 2010 through July 2011 were reviewed on July 26, 2011. Per regulation, the residential facility shall conduct a fire drill during sleeping hours at least every six months. Sleeping hours at the facility are from 9:30 PM until 7:00 AM. The facility conducted fire drills during sleeping hours on the following dates: July 5, 2010 at 3:15 AM, March 22, 2011 at 11:40 PM and May 5, 2011 at 6:50 AM. Based on the July 5, 2010 fire drill documentation, the facility was due to complete a fire drill during sleeping hours no later than January 5, 2011. The facility did not document a fire drill during sleeping hours until March 22, 2011. This was a lapse of more than eight months between fire drills during sleeping hours.
The project/facility director was interviewed July 26, 2011 at approximately 3:30 PM. The project/facility director confirmed that a fire drill during sleeping hours had not been conducted every six months.
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Plan of Correction
While we actually had documented three registered middle of the night alarms, the Peniel Fire Marshall will assure the alarms during sleeping hours are unannounced and at least every six months by scheduling them in advance on the master calendar. |