Observations
Based on a review of the facility's April 2023 through February 2024 fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
There was no documentation of a fire drill being conducted during the month of November 2023. Additionally, every fire drill log reviewed documented that no building occupants were evacuated during the drills. The facility previously had a Department-approved alternative procedure for not evacuating the building during fire drills; however, the approval expired when the Governor ' s Proclamation of Disaster Emergency related to COVID-19 ended on June 19, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO, Director of Performance Improvement and the Director of Plant Operations reviewed this finding. The CEO and Performance Improvement Director provided education to the Director of Plant Operations on the requirements for unannounced and documented fire drills at least monthly. On-going the Director of Plant Operations will facilitate, conduct, and document unannounced fire drills at least once a month and ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. Fire Safety compliance will be reported quarterly to the Performance Improvement Committee. |