Observations Based on a review of the fire drill log and staff interviews it was determined that the facility failed to conduct a fire drill during sleeping hours within the past six months.
The findings were:
A review of the fire drill log was conducted on August 2, 2010. The last documented fire drill during sleeping hours occurred on August 1, 2009 at 12:00 AM. A conversation with the facility director on August 2, 2010 confirmed that no fire drill was conducted during sleeping hours since that time.
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Plan of Correction The Facility failed to conduct a fire drill during the last six months.
The Facility conducted a Sleeping fire drill on 08/02/2010.
The Operations Manager will make sure that sleep time fire drills will be conducted every six months. This will be followed up be the Business Manager.
This will be in effect immediately. |