Observations
Based off of a review of facility records, the facility failed to complete a fire drill during sleeping hours at least every six months.
Fire drill logs provided by the facility documented a fire drill occurring during sleeping hours on January 23, 2023 at 12:50am. The next fire drill during sleeping hours was due no later than July 31, 2023. The next fire drill during sleeping hours was documented on September 21, 2023 at 12:47am. Fire drills were reviewed from November 2022 through September 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Implementation of fire drills once a month. Implementation of fire drill each quarter will include all 3 shifts. The day 7AM to 3PM, evening 3PM to 11pm and overnight shifts 11PM to 7AM. The fire drill will be submitted into Gateway's incident management system that will be send to facility clinical manager & director for review.
Health & Safety inspections will be conducted for monthly and quarterly fire drills. Health & Safety Inspection results will be reported to monthly Health & Safety committee. |