Observations
Based on a review of fire drill logs, the facility failed to document the use of alternate exits during fire drills.
The fire drill logs were reviewed for the time period of April 2021 - March 2022. There were no alternate exits used during this time period. All monthly drills documented the use of the same exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding 705.28 Fire Safety Regulation and Deerfield's failure to comply with a mandatory monthly fire drill and documentation for non-residential facilities- The Clinical Director of Drug and Alcohol Treatment Programming will, starting in April of 2022, be responsible for the rotating monthly fire drill within all Deerfield outpatient programming. The Clinical Director will perform fire drills on a monthly rotation of AM and PM times, rotation of front exit and back exit departure and count of building occupants, and documentation into fire safety binder by location, date, and time of the drill.
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