Observations
Based on a review of the January 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.The facility's hours of operation are Monday through Friday 7:45AM - 8:00PM. All fire drills conducted, during the reviewed period, were completed from the hours of 7:30AM - 3:00PM. None of the fire drills were conducted during the facility's evening hours of operation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward to abide by this DDAP regulation, the office managers with the support of the clinical supervisors will complete a fire drill on different business days of the week (Monday-Friday), at different times of the day including morning, afternoon, and evening hours within the scope of posted facility hours. This will commence immediately and have full compliance by correction action date. Clinical supervisor will review monthly fire drills to ensure full compliance. |