Observations
Based on a review of fire drill logs and an interview with the director and the treatment supervisor, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on August 31, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of July 2009 to August 2010. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the fire drills documented on July 24, 2009, September 29, 2009, October 15, 2009, December 15, 2009, January 6, 2010, February 12, 2010, March 9, 2010, April 5, 2010, June 23, 2010 and August 17, 2010.
The director and the treatment supervisor was interviewed on August 31 and September l, 2010, and confirmed the fire alarm or smoke detector was not activated each month. The facility is located in a building with other occupants, and the fire systems are tested four times per year.
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Plan of Correction
In response to being out of compliance for 705.28 Fire safety. On September 9, 2010 Fayette County Drug And Alcohol Commission, Inc. summited a letter to the Departmetn of Health requesting exception to section 705.28(d)(7). Fayette County Drug Alcohol Commission Inc. recieved a letter from the Department of Health dated September 16, 2010 stating that an exception is not needed, but approval has been granted for alternate means of announcing fire drills. |