Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The Fire Drill Log was reviewed on September 30, 2014. The facility failed to conduct a fire drill during sleeping hours at least every 6 months. The facility conducted two fire drills during sleeping hours twelve months apart; one on June 4, 2013 and the other on June 19, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff on duty is responsible for conducting a fire drill during sleeping hours and is responsible for the proper documentation.
Clinical Supervisor is responsible for ensuring that staff conduct the fire drill at least every 6 months.
Program director is responsible for the overall compliance.
Staff on duty have been notified of fire drills during sleeping houses and will be re-trained in fire drill compliance at staff meeting on 12/15/14. |