Observations
Based on a review of fire drill logs from September, 2025- April, 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of January through April, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28d5 The Facility Director will meet with clinical directors, clinical staff, and administrative staff to review 705.28d5 and educate all staff of regulation. Clinical and/or administrative staff will submit monthly fire drill logs to the Facility Director for review. This will be in compliance effective 6/18/2026. Compliance with this standard will be enforced and monitored by the Facility Director through monthly fire drill log reviews, staff meetings and ongoing staff training. |