Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The fire drill logs were reviewed during an administrative review and the time period of August 2020 - August 2021 was reviewed. There was documentation of one fire drill during sleeping hours in that time period. That drill was conducted in March 2021. Another fire drill during sleeping hours was due to be completed by September 2021; however, there was no documentation of any additional fire drills during sleeping hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Staff conducted fire drill during sleeping hours, on September 2021. The drill was recorded in Gateway's D3 fire drill log.
The facility manager & director will maintain a schedule of all required fire drills. This will include required fire drills during sleeping hours at minimal every six months.
Upon completion of overnight drills staff record results of drill in Gateway's D3 system/fire drill log and submit an email to manager/director confirming drill was completed.
GRC Risk management committee will monitor all fire drills submitted on D-3 system and send monthly report to director for follow-up.
Director will review report to ensure that fire drill during sleeping hours are being completed. |