The purpose of the drill is to confirm staff can perform their fire response duties, not to evacuate patients. Surveyors read the drill records and then ask staff on the floor to describe their role.
Health care occupancies: hospitals, nursing facilities, inpatient rehabilitation
- Fire drills quarterly on each shift
- Drills conducted at unexpected times and under varying conditions
- Between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms
- Staff trained in the fire plan and their specific duties, with transmission of the alarm, containment, extinguishment and evacuation to a smoke compartment
Ambulatory health care occupancies: surgery centers
- Fire drills quarterly on each shift
- Staff instructed in the fire plan and their duties
- Drills may be announced in advance to protect patients undergoing procedures
What the drill record should show
- Date, time and shift
- Location and simulated fire scenario
- Alarm transmission and response time
- Staff who participated and their performance
- Deficiencies identified and corrective actions
- Signature of the person conducting the drill
Common citations
Missing drills on the night shift, four drills a year all at 10:00 a.m., records with no critique and no staff names, and staff who cannot describe the fire plan when asked. Each is correctable with a drill calendar by shift and a standard record form.
Frequently asked questions
One per shift per quarter. A hospital running three shifts needs twelve drills a year, spread across all shifts.