Observations
Based on a review of the facility's fire drill log and an interview with the facility director, the facility failed to document a fire drill during sleeping hours at least every six months. The findings include:The facility's fire drill log was reviewed December 16, 2010. The facility did not document a fire drill during sleeping hours at least every six months. The facility's last documented fire drill during sleeping hours was on August 27, 2009. An interview with the facility director on December 16, 2010 confirmed that fire drills were not conducted at least once every six months during sleeping hours. This is a repeat citation. The facility was cited on 1/8/10 for failing to conduct a fire drill during sleeping hours.
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Plan of Correction
The following steps will be implemented: 1) Review of the regulation with the Residential and Associate Director; 2) review of the regulation with all 24-hour staff and the Lead House Manager; 3) two-drills will be scheduled during sleeping hours and the Program Director will be informed of the dates, the implementation, and the outcomes of these drills.
Fire Drill will be completed on 2/1/11.
Person (s) responsible: Program Director, Associate Director, and Lead House Manager
Timeframe for completion: Immediate |