The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)).
The legal entity will create a fire drill log and fire alarm testing plan. It must include a list of all upcoming specified dates and times of when each fire drill and fire alarm testing will occur over the next 12 months. This plan must include the name of the designated staff person assigned to maintain the facility's fire drill log and fire alarm testing log. This plan must have a sheet for staff to sign off to verify their individual participation in each drill. This fire drill log and fire alarm testing plan will be sent to OCDEL for approval, and will be used by facility to conduct fire drills and complete fire alarm testing at those specific dates and times through the calendar year. All scheduled fire drills and fire alarm tests completed within the next 180 days must be logged, with all required information documented according to regulation and the facility's written plan, and sent to OCDEL for review within 1 week of the completion of each fire drill and each fire alarm test.
During a complaint investigation on 5/17/23, the facility staff #2-#8 communicated both verbally and provided written statements verifying that fire drills were not being conducted every 60 days. The facility's written fire drill log documented fire drills conducted on 5/20/22, 7/14/22, 9/2/22, 10/13/22, 12/5/22, 1/10/23, 9/7/23, and 5/9/23. However, staff person #2 and #3 both stated in writing that the only fire drill that the facility actually participated in between May 2022 - May 2023 was completed on 5/9/23, and staff person #2 stated they were responsible for completing the fire drill logs.
Also observed during the complaint investigation, the documentation on file regarding the testing of the fire alarms was not adequate. The facility is required to complete fire alarm testing every 30 days; facility had never verbalized any reason as to why this was not possible to complete and understood the need for testing according to compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The testing report provided from the fire alarm company showed only 3 dates over the course of the last 12 months as a verified documented test of the alarms being pulled; those dates are: 6/30/22, 11/3/22, and 5/9/23. Documentation on file written by staff #2 shows a gap in the 30 day alarm tests recorded between May 2022- May 2023. Dates of record tests written by staff #2 are as follows: 5/20/22, 6/30/22, 7/14/22, 8/26/22, 9/2/22, 10/13/22, 11/3/22, 12/5/22, 1/10/23, 2/9/23, 3/7/23, 4/7/23, 5/9/23. In addition, the facility provided an invoice from their alarm company dated 1/16/23, which documented that an annual inspection/lights was last completed on 1/21/20, which is more than 12 months from the date of inspection.
3270.94(a)(1)/3270.95(a) · Corrected Dec 28, 2023