Observations
Based on a review of administrative information, the facility failed to ensure a fire alarm or a smoke detector was set off during each fire drill.
Fire drill logs were reviewed from April 2023 to January 2024. A fire alarm or a smoke detector was not set off for fire drills documented for August, October, November, December 2023 and January 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The agency has requested a waiver for this regulation in that the buildings house multiple programs and an agency wide alarm would cause negative disruptions to many clients and providers.
Should the request for a waiver not be granted, the agency will utilize an alarm system for the D&A offices of the building only. This would decrease disruption to other therapeutic services occurring in the building.
The D&A therapist within the agency has joined the agency wide safety committee which meets on a monthly basis and reviews all fire drills, obstacles encountered and changes required. The safety committee also reviews general safety procedures for the agency.
The safety committee will complete 2 fire drills per year with the alarm sounded and emergency personnel responding on scene.
All D&A Staff reviewed the protocol for fire drills during a staff review of audit results on 3/7/2024. |