| 6400.112(d) | The fire drill completed in March 2025 lasted 4 minutes. There was no explanation given nor was an additional drill completed in the month. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | On March 24, 2025, staff conducted a fire drill at the UFIL residence located at Individual #2¿s residence. The recorded evacuation time was 4 minutes, exceeding the regulatory maximum of 2 ½ minutes. Upon submission, the drill was deemed noncompliant.
A supervisory debrief revealed the cause of the delay: the staff member was unable to access the mounted smoke detector to activate the alarm. As an improvised solution, she used a fire alarm sound on her personal cell phone. However, the resident reported that the sound was not loud enough, which contributed to the delayed response.
To correct this, the Program Supervisor immediately modeled proper fire drill protocol using a handheld air horn, a tool recommended for drills when smoke detectors cannot be triggered. Staff were instructed to repeat the fire drill using this method. A successful drill was conducted on March 29, 2025, at 4:18 AM, with an evacuation time of 1 minute and 30 seconds, well within compliance. This drill was properly documented, including duration, time, date, and exit route. The air horn used in the drill has now been permanently stationed in an accessible location within the residence. All fire drill documentation has been updated to reflect both the original failed attempt and the successful reattempt. The staff involved received immediate retraining on proper fire drill procedures and documentation protocols. |
06/21/2025
| Implemented |