Helpful Hints: Top 10 Life Safety Compliance Deficiencies of 2011 - Part 8
By Steve Swedish, Windmill Software
I hope that you found
last week's entry #7 on the Top Ten Life Safety Citations of
2011, K144 Generator Installations, Maintenance and Testing to be
helpful. Moving down to #8 on the list this week, we have
K50 Fire Drills. It's not only important to run
the Fire Drill with all of your staff for each shift, you also need
to have the documentation on hand when you're going through survey.
If you can't find it, you're going to get cited!
K50 -Fire Drills
Ensure that the facility administration has a plan that has been
distributed for the protection of all persons in the event of fire,
for their evacuation to areas of refuge, and for their evacuation
from the building when necessary. Establish a system to ensure that
all employees are periodically instructed and kept informed with
respect to their duties under the plan.
It's necessary to monitor fire drills to ensure that the drill
includes the transmission of a fire alarm signal and simulation of
emergency fire conditions. There also needs to be a documented
receipt or verification of call to remote monitoring company (This
can be stored in TheWorxHub).
You must monitor fire drills to ensure that drills are held
quarterly, per shift, at unexpected times and under varying
Maintain documentation concerning fire drills for the preceding
12 months that shows at least the following:
- Differing times for drills conducted on each shift. Drills
should be conducted at various times throughout the shift to avoid
patterns. Fire drills that occur within one hour may be considered
as having occurred at the same time.
- One drill per shift per quarter. Drills conducted at shift
change are only counted for one shift. If a drill is conducted
January 1st, then another drill must be conducted by April 30th to
meet the quarterly requirement.
- Identity of the person conducting the drill
- Number evacuated
- Problems encountered
- Weather conditions when evacuated outside
- Time required to complete the drill
- Differing days of the week including weekends.
- Involvement of all departments.
- Documented observations of staff response.
- Duties of Staff
- Many Communities break this down by staff type or job type
- Record of equipment functioning such as the release of doors
and alarms sounding.
- Between the hours of 9:00 PM to 6:00 AM a silent alarm may be
used instead of the audible alarm or a coded announcement
- Digital Alarm Communicator Transmitter (DACT) testing must
occur during each drill per NFPA 72
- Document the time the alarm monitoring company received the
- When conducting a silent alarm, ensure that the alarm is tested
the following morning noting the time the alarm signal was
Helpful Hints to Avoid a K50 Citation
- 3 of the 4 fire drills within an hour of each other are viewed
to establish of a pattern of non-compliance
- Document as much detail as necessary to prove fire drills were
done with all staff participating signing the signature sheet
(Without the signature sheet you can get cited)
- If the fire alarm system hasn't already been activated, staff
should be expected to activate the nearest fire alarm box. Because
the alarm is to be sounded during drills, it's important that the
company or agency monitoring the fire alarm system be notified in
advance of the drill to avoid dispatching the fire department. It's
equally important that the monitoring company/agency be contacted
after the drill to verify the time that an alarm signal was
received and to serve notice that the drill has been
- The drill must include complete evacuation of the smoke
compartment containing the area of simulated fire origin and all
occupants moved to a safe location (e.g. an adjacent smoke
compartment or another floor). The emphasis when conducting drills
needs to be on safe and orderly evacuation rather than speed.
- Varying conditions of drill to simulate the unusual conditions
that can occur in an actual fire. Fire is unpredictable.
- Staff must be able to react to the conditions present and
adjust their actions accordingly to ensure a safe and orderly
evacuation. Conducting drills at varying times using different
locations and scenarios not only tests their ability to do so, but
makes them confident enough that the potential for confusion or
panic under actual fire conditions is significantly reduced. If
staff can remain calm and self-assured under emergency conditions,
there is less likelihood of upsetting or exciting the facility's
residents and visitors.
- An important part of each drill is the practicing of your
facility's procedures for accounting for employees and occupants
(including visitors) after evacuation has been completed. If a
method isn't in place to account for everyone once evacuation or
relocation is complete, it is difficult to measure the success of
your fire safety/evacuation plan. It also makes search, rescue and
fire attack activities more difficult for emergency
It's important that at least two people in your facility know
where your drill records are kept to increase the likelihood that
they can be readily provided if requested during a survey. It is
recommended that these records be maintained for at least three
Fire drills are an extremely important part of Fire Safety in
your building. Making sure that all staff not only knows, but also
practices what to do in the event of a fire and how to help the
residences are key components of a safe evacuation.
As I do every week, I encourage you to share your experiences
that you've had with K50, it could help one of your peers reading
avoid a headache.
Next week I'll be writing about the #9 most cited K Tag for
2011, K56 Automatic Sprinkler Systems.
I look forward to talking with you then and have a great
Top 10 Deficiencies and How to Avoid Them, Indiana State
Department of Health
Preventative Maintenance Manual, Ohio
Department of Health
So That's What They Look For, CMS
This entry was written by Wednesday, December 05, 2012
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