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 conditions.
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.
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- 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 (19.7.1.2).
- Digital Alarm Communicator Transmitter (DACT) testing must occur during each drill per NFPA 72
- Document the time the alarm monitoring company received the alarm.
- When conducting a silent alarm, ensure that the alarm is tested the following morning noting the time the alarm signal was received.
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 completed.
- 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.
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- 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 responders.
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 years.
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 week!
Sources:
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
