Observations
Based on a review of the fire drill logs and an interview with the clinical supervisor, the facility failed to prepare alternate exit routes to be used during fire drills, as required by regulation.
The findings include:
A review of the fire drill logs was conducted on September 21, 2011. The fire drills conducted from January - August 2011 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility failed to document alternate exits used during fire drills. The exit route used during the fire drill was not documented for the drills conducted in January, February, March, April, May, June, July and August 2011.
An interview with the clinical supervisor was conducted on September 21, 2011. It was confirmed that the front door exit route was the only exit used for drills.
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Plan of Correction
The Director of Outpatient will ensure that the Bedford office is practicing fire drills once per month and documenting on their fire safety form the exit route they used during that drill. The Bedford office will alternate which exit route they use each month with no discernible pattern; however, each route will be used 6 times each year. This will begin on 12/1/11 with the fire drills that month. |