Observations Based on a review of fire drill records, the facility failed to conduct fire drills on different days of the week.
Fire drill logs were reviewed from June 2025 through May 2026. Fire drills took place on the following dates: June 9, 2025, July 7, 2025, August 4, 2025, September 1, 2025, October 6, 2025, November 3, 2025, December 1, 2025, January 5, 2026, February 2, 2026, March 2, 2026, April 6, 2026, and May 4, 2026. All fire drills were conducted on a Monday.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction "Administrative assistant & counselor in each office were trained to conduct fire drills on 6/12/2026. Administrative assistant & counselor will complete documentation reflecting random dates & shifts of fire drills conducted.
Clinical Supervisor will review documentation of random fire drills on the last day of each month.
All Fire Drill logs will be reviewed each quarter by Facility Director." |