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:
The fire drill logs were reviewed on June 30, 2015. The time period reviewed was July 2014 through May 2015. The facility did not document any alternate exits used during fire drills. All fire drills documented indicated the use of front and side exits.
The findings were discussed with staff during the licensing process.
|
Plan of Correction
The Safety Officer of the building will hold monthly fire drills. Starting in July 22,2015,Fire drills will focus on using alternate exists. July front-back exist, August the front exit, September the back exit, October both front and back exits, November front exit, December back exit, January front-back exits, February front exit, March back exit, April both exits, May front exit, June back exit, July both exits, August front exit, September back exit.
The Compliance Officer and Facility Director will ensure implementation of the schedule by reviewing the fire drill log monthly with the Safety Officer of the building. This POC has been in effect since July 22, 2015.
|