From some of our earliest memories in elementary school as little kids, we all recall participating in fire drills on a periodic basis. Of course, the purpose of those fire drills was to train students, faculty and staff to respond appropriately to the activation of the building’s fire alarm system in a consistent and efficient manner.

Long-term care providers are also compelled to conduct fire drills on a very specific schedule to help promote levels of safety and preparedness within their environment of care.

While the process of conducting fire drills in a LTC facility on a frequency of one drill, per shift, per quarter is certainly not a new concept, skilled nursing facilities regulated by the Centers for Medicare & Medicaid Services continue to receive deficiencies related to this requirement on a regular basis.  

Surprisingly, these drills continue to be cited as one of the most common deficiencies in SNFs on a national level (K-712) and are almost always in the top 10 Life Safety tags in each state.

Here are the requirements cited in NFPA 101, The Life Safety Code (2012 edition) and surveyed under tag K-712:

“Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7“

One of the main reasons that providers continue to receive this deficiency (K-712) is because they fail to conduct drills at “unexpected times” under varying conditions. Instead, many skilled nursing facilities will get into a rut and conduct drills at predictable times on each shift during each quarter.

Example: All fire drills during the year on the first shift (7:00 a.m. – 3:30 p.m.) are conducted around 10:00 a.m. on the first Monday of the first week of each quarter.  This type of schedule would be considered predictable. 

Example: All NOC shift fire drills are conducted around 5:30 a.m. during each quarter when the facility’s maintenance director reports to work early to conduct the quarterly drill. A surveyor would likely deem this practice as predictable and not in compliance with the requirement that the drill occurs at unexpected times.

In addition to the issue of predictability, another deficiency often identified is poor documentation. While some providers may think it is advantageous to document all fire drills in a consistent manner that cites only successful drills, the reality is that each drill is unique and proficiencies vary from drill to drill. Life Safety surveyors expect to see a realistic assessment of fire drills to capture the facts and cite opportunities for improvement.  

Fire drills give LTC professionals the ability to practice emergency procedures and identify areas in need of additional attention. Capturing this information in a comprehensive fire drill record will give surveyors a realistic impression of a facility’s fire drill program.  Don’t be afraid to document a drill that wasn’t an A+ and record items in need of improvement. That is the type of information surveyors expect to be included on written fire drill records.

One of my favorite sayings when it comes to the management of Life Safety Code regimens and requirements in a LTC facility is: “This isn’t rocket science.”  The facilitation of fire drills requires a person or team that is competent and capable of planning, implementing and conducting a realistic performance review of a drill.  

Your facility should have a fire drill document that captures all of the basic elements of compliance, including the following:

  • Name and address of facility
  • Date and time of drill
  • Shift and quarter in which the drill is being conducted
  • Summary of the scenario being simulated (example: Report of smoke in room 205)
  • Identify if the drill includes fire alarm system activation or is a silent drill (as allowed between 9:00 p.m. and 6:00 a.m.)
  • Name of person conducting the drill
  • Information confirming that fire response procedures were utilized, including the R.A.C.E. and P.A.S.S. protocols
  • Cite the time the fire alarm system was taken out of service for the drill
  • Cite the time the fire alarm system was placed back in service following the drill
  • Summary of performance
  • Summary of opportunities for improvement
  • Sign-in sheet with signatures of all participants

Fire drills are a critical component of every LTC facility’s Life Safety Code compliance program and should be managed by someone who possesses the skills and leadership abilities required by K-712. Conducting drills at unpredictable times using varying scenarios, along with proper documentation, will help promote compliance and survey success. Most importantly, a good fire drill program will condition your staff to be ready to respond to fire emergencies in a consistent and efficient manner.

Stan Szpytek is the president of the national consulting firm, Fire and Life Safety Inc. based in Mesa, AZ. He  is the Life Safety/Disaster Planning Consultant for the Arizona Health Care Association, California Association of Health Facilities (CAHF) and Utah Health Care Association, and is a consultant for the American Assisted Living Association (AALNA). Szpytek is a former deputy fire chief and fire marshal with more than 40 years of experience in life safety compliance and emergency preparedness. For more information, visit www.FLSafety.org or e-mail Szpytek at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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