Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on December 19, 2012. The fire drills conducted from December 2011 - November 2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The exit route used during the fire drill was not documented for the drills conducted in December 2011, January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, July 2012, August 2012, September 2012, October 2012 and November 2012. It could not be determined from the fire drill logs if alternate exits were used.
An interview with the facility director was conducted on December 19, 2012. It was confirmed that the exit route used was not identified in the fire drill logs.
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Plan of Correction
Pursuant to the observation made during the 12/19/12 inspection, the Facility Director will utilize both the front and rear egresses, on at least a quarterly basis during fire drills. The facility is a single story plant, with a front and rear exit. This will be documented for review in the facilities fire drill log. It will have secondary review from the facilities Lead Counselor. The facility will begin utilizing both egresses beginning January 2013. |