| 2380.89(a) | There were no fire drills conducted in the months of January and February 2026. | An unannounced fire drill shall be held at least once a month. | TeamPHCA reviewed the circumstances surrounding the missed January 2026 and February 2026 fire drills to determine the cause of the non-compliance and the corrective actions necessary to address the cited violation. The review determined that during January 2026 and February 2026, TeamPHCA believed that participation by the local fire department was necessary in order to conduct the required monthly fire drills. Based upon this understanding, TeamPHCA attempted to coordinate the required fire drills through the local fire department rather than independently conducting the drills at the facility.
TeamPHCA made attempts to contact and coordinate with the local fire department regarding the completion of the fire drills. Documentation of TeamPHCA's communications and attempts to coordinate with the local fire department was maintained and is available for review. These attempts demonstrate the actions TeamPHCA was taking during January and February 2026 based upon its understanding of the fire drill process at that time.
TeamPHCA subsequently learned that participation by the local fire department was not required for TeamPHCA to satisfy its responsibility to conduct monthly unannounced fire drills. TeamPHCA learned that the provider could and was responsible for independently conducting the required unannounced fire drills at the facility without waiting for the local fire department to participate.
Once TeamPHCA learned that it could independently conduct the required monthly fire drills, TeamPHCA immediately changed its practice. Effective March 2026, TeamPHCA began independently conducting and documenting its own monthly unannounced fire drills. TeamPHCA no longer waited for the local fire department to be available before conducting the required monthly fire drill.
The corrective action specifically addresses the January 2026 and February 2026 fire drills cited in the Licensing Inspection Summary. Because January and February 2026 have passed, TeamPHCA recognizes that the missed drills cannot be recreated retroactively. Therefore, TeamPHCA's corrective action addresses the circumstances that resulted in the missed drills, correction of the misunderstanding regarding fire department participation, implementation of the correct fire drill process beginning in March 2026, review of the provider's subsequent fire drill records, assignment of responsibility, staff training, and validation that the corrected process has been implemented.
As part of the corrective action process, TeamPHCA conducted a review of fire drills after March 2026, rather than limiting its review to the January and February 2026 months identified through the licensing sample. The purpose of this review was to determine whether any other months were affected by the same issue and to verify that the corrected practice was implemented following TeamPHCA's discovery that the facility could independently conduct its monthly fire drills.
The review included fire drill documentation beginning with the implementation of the corrected practice in March 2026 and the available records thereafter. TeamPHCA reviewed the records to verify that the required monthly fire drills were being conducted and documented following implementation of the corrected procedure. Any deficiency identified through TeamPHCA's review will be addressed and documented as part of the provider's corrective action process.
The Executive Director has been designated as the person responsible for oversight of the corrective action. The Executive Director will be responsible for ensuring that an unannounced fire drill is conducted and documented at least once during each calendar month in accordance with the applicable regulatory requirements.
The Executive Director's responsibility includes ensuring that the monthly fire drill is not dependent upon the availability, participation, scheduling, or response of the local fire department. Although TeamPHCA may communicate or coordinate with emergency response agencies when appropriate, such communication will not delay or replace TeamPHCA's responsibility to independently conduct its required monthly fire drills.
The Executive Director is also responsible for ensuring that each completed fire drill is appropriately documented. The documentation will identify the applicable date and time of the drill and other information required by TeamPHCA's fire drill procedure and applicable regulatory requirements. The Executive Director will review the completed documentation to ensure that the record demonstrates that the required monthly drill was conducted and that the documentation is complete.
The Executive Director has received training regarding the monthly fire drill requirements. The training addressed TeamPHCA's responsibility to independently conduct the required monthly unannounced fire drills, the fact that participation by the local fire department is not required in order for TeamPHCA to conduct the drills, the applicable documentation requirements, and the Executive Director's specific responsibilities for implementation and oversight of this Plan of Correction.
The training further addressed the circumstances surrounding the January and February 2026 non-compliance so that the misunderstanding that contributed to the missed fire drills does not continue. The Executive Director was instructed that the facility's responsibility to conduct its monthly fire drill remains in effect regardless of whether the local fire department is available to participate.
TeamPHCA has incorporated the corrected fire drill process into its operating practices. The correction is not based solely upon a future promise to conduct or monitor fire drills. TeamPHCA implemented the corrected practice beginning in March 2026, and completed fire drill documentation from the period following implementation will be provided as evidence that the new practice was placed into operation.
To validate the corrective actions described in this Plan of Correction, TeamPHCA will provide supporting documentation to the licensing representative. Each attachment will be clearly labeled and will correspond with the corrective action described in this Plan of Correction.
Attachment #1 -- Fire Department Communication Documentation: Documentation demonstrating TeamPHCA's attempts to contact and coordinate the January 2026 and February 2026 fire drills through the local fire department. This documentation supports TeamPHCA's explanation regarding the circumstances that contributed to the missed January and February 2026 fire drills.
Attachment #2 -- Executive Director Training Documentation: Documentation verifying that the Executive Director received training regarding the monthly fire drill requirements, TeamPHCA's responsibility to independently conduct the required drills, documentation requirements, and the Executive Director's specific responsibilities for implementing and overseeing the corrective action.
TeamPHCA acknowledges the requirement to conduct an unannounced fire drill at least monthly and has corrected the misunderstanding that resulted in the January 2026 and February 2026 fire drills not being conducted. The provider's practice was corrected effective March 2026, when TeamPHCA began independently conducting its monthly unannounced fire drills.
Through the corrective actions described above, TeamPHCA has addressed the specific January and February 2026 violation, reviewed the applicable fire drill records to identify whether the issue affected any other months, established clear responsibility with the Executive Director, provided training regarding the corrected process, and maintained documentation demonstrating that the corrected practice has been implemented.
The supporting documentation identified as Attachments #1 through #3 will be provided to validate the circumstances surrounding the original non-compliance and TeamPHCA's implementation of the corrective action. |
03/01/2026
| Implemented |