Observations
Based on a review of fire drill records and an interview with the facility director, the facility failed to provide documentation that the facility's alarm is in working order.
The findings include:
Fire drill records were reviewed on February 25, 2014. The records were reviewed from the period covering April 2013 to February 2014. The facility was granted an approval on April 2, 2008 to the Physical Plant Standards for Nonresidential Facilities, Chapter 705.28 (d) (7), relative to activating a fire alarm or smoke detector during a fire drill. As a result of the approval, the facility was required to provide documentation that their fire alarm is in working order. Documentation that the facility's fire alarm is in working order was not presented for review.
The findings were confirmed during an interview with the facility director on February 25, 2014 at approximately 2:00 P.M.
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Plan of Correction
Site Director has obtained documentation that the building fire alarms were tested on 7/10/2013, and were in good working order. Site Director also verified with building manager that the inspection is conducted annually in July or August. Site Director will obtain documentation of the fire inspection annually going forward and file it in the site binder with the documentation of the monthly fire drills. |