Initial Comments:
A focused fundamental survey was conducted June 2 - 7, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was 20 and the core sample consisted of four individuals.
Plan of Correction:
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
The facility must hold evacuation drills under varied conditions.
Observations:
Based on facility provided documentation and interview, it was determined the facility failed to conduct fire drills under varied conditions for staff in two of three cottages. Findings included:
A review of the facility's fire evacuation drills was completed on June 7, 2021. The fire drill documentation revealed that the basement exit has not been practiced in cottage #1 and #3.
An interview was held with the director on June 7, 2021, at 1:00 PM. The director confirmed that the basement exit was not practiced in cottage #1 and #3.
Plan of Correction:All future, unannounced fire drills will include utilization of the basement exit as the only choice to exit the cottages. A fire drill will be run in August 2021 in which the only exit to be used is the basement exit. Moving forward (effective 7/1/21), future fire drills will also include a drill in which the basement exit will be scheduled as the only exit at least one time in each 6 month period. For example, from January to June one drill will be implemented utilizing only the basement exit; and from July to December a drill will be run utilizing only the basement exit. The Director of IDD is responsible for monitoring this area; the fire drills for the cottages are reviewed monthly for compliance in all areas. As an additional monitoring check, the Director of IDD and the Executive Director review all fire drills monthly and sign off on the actual drill report, thus verifying compliance in all required areas.
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