Observations Based on a physical plant inspection and review on monthly fire drills, The facility failed to conduct monthly fire drills..
The findings include:
A review of fire drills from January 3, 2012 to January 4, 2013 was conducted on January 9, 2013. The facility failed to complete a monthly fire drill in July 2012 and November 2012.
A monthly fire drill was completed in January, February, March, April, May, June, August, September, October and December 2012.
The Facility Director confirmed this finding on January 9, 2013.
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Plan of Correction Effective March 1, 2013, the Outpatient Clinical Suprvisor or Counselor shall be requred to provide a weekly report to the Facility Director that shall include information related to conducted fire drills, e.g.date, time, exit used.
Utilizing the information received, the Facility Director shall ensure that monthly fire drills are conducted as required.
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