Initial Comments:
A focused fundamental survey was conducted June 3-6, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was five and the sample consisted of three individuals. Two deficiencies were cited.
Plan of Correction:
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure evacuation drills were conducted at least quarterly per shift of personnel. This was noted for the third shift of personnel. The findings included:
A) Facility fire drills from the past year were reviewed on June 3, 2024. This review revealed that there was no third shift fire drill conducted during the first quarter of 2024 (January, February, March).
B) The program director (PD) was interviewed on June 4, 2024, at 9:30 AM. The PD confirmed that there was no third shift fire drill conducted during the first quarter of 2024.
Plan of Correction:The Program Coordinator will train the Supervisor to hold evacuation drills at least quarterly for each shift of personnel. Training will focus on ensuring evacuation drills are held on each of the three shifts each quarter of the calendar year, including 3rd shift. Training will include a review of the Fire Drill Schedule for the remainder of 2, developed by the Program Director, to assist in assuring compliance. Training will take place by July 12, 2024 and the Program Director will sign and date the training to assure completion. Training records will be maintained in the personnel files.
The Program Coordinator and will monitor monthly fire drills on an ongoing basis to ensure drills are held at least quarterly for each shift of personnel, according to the schedule.
Immediately following the drill, the Supervisor will send a text message the Program Coordinator confirmation the drill was completed, and the time it took to evacuate the home. Within 72 hours of a fire drill, the Supervisor will scan and email the designated documentation paperwork to the Quality Management Specialist, Program Coordinator, and Program Director who will review fire drills and monitor to ensure they are being done as per the schedule. If the drill is not preformed according to the schedule, another drill will be held that quarter at the specified time, as per the schedule. For the next 6 months, the Coordinator, or designee, will respond to the e-mail documenting her review, and documenting whether or not another drill needs to be conducted. Fire drill reports will be maintained at the facility. The Supervisor will print e-mail threads and place them in the Plan of Correction binder.
If there are no problems noted, moving forward the Coordinator will still monitor the drills to assure drills are done at least quarterly for each shift of personnel however the Coordinator may only respond if problems are noted. The Quality Management Specialist will oversee reviewing the fire drill report and providing feedback if corrective actions are needed. The Quality Management Specialist may only respond if problems are noted.
Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure fire drills were conducted under varied conditions. This was noted for all four first shift fire drills conducted in the last year. The findings included:
A) Fire drills from the past year were reviewed on June 3, 2024. This review revealed that all four of the fire drills that were conducted during the first shift of personnel were conducted on a Sunday.
B) The program director (PD) was interviewed on June 3, 2024, at 1:10 PM. The PD confirmed that the four first shift fire drills from the last year were not conducted under varied conditions.
Plan of Correction:The Program Coordinator will train the Supervisor to hold evacuation drills under varied conditions. Training will include, but not be limited to, ensuring evacuation drills are held under varied conditions, which includes varied days of the week. The training will include a review of the fire drill schedule for 2024, which specifies first shift fire drills under varied conditions for the remainder of the year, and an auditing form, developed by the Program Director, to assist in assuring compliance. Training will take place by July 12, 2024 and the Program Director will sign and date the training to ensure completion. Training records will be maintained in the personnel files.
The Program Coordinator and will monitor monthly fire drills for the next year to ensure drills are held under varied conditions including ensuring evacuation drills are held under varied conditions, according to the schedule. For the next six months, if the drill is not preformed according to the schedule, another drill will be held that quarter at the specified time, as per the schedule. The Supervisor will scan and email all fire drills to the Quality Management Specialist, Program Coordinator, and Program Director who will review fire drills and monitor to ensure they are being done as per the schedule. The Program Coordinator, or designee, will respond to the e-mail documenting her review. Fire drill reports will be maintained at the facility.
The Supervisor will print e-mail threads and place them in the Plan of Correction binder.
If there are no problems noted, moving forward the Coordinator will still monitor the drills to assure drills are done at least quarterly for each shift of personnel however the Coordinator may only respond if problems are noted. The Quality Management Specialist will oversee reviewing the fire drill report and providing feedback if corrective actions are needed. The Quality Management Specialist may only respond if problems are noted.
Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.
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