705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the August, 2021 through June, 2022 fire drill logs during the inspection, the facility failed to document the number of persons in the facility at the time of the drill on April 14, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Safety committee at the community guidance center will review all fire drills and completion of fire drill paperwork to ensure accuracy and completion of the forms. Staff training will be conducted with those on the safety committee to assure complete documentation of forms. Training with the safety committee will occur on 9/7/2022 during their meeting. |
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #3 was admitted on January 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 1, 2022 and the next update was due no later than April 1, 2022; however, the next update was completed on April 22, 2022. Additionally, the following update was due no later than June 22, 2022; however, it was not completed until July 6, 2022.
Client #4 was admitted on February 7, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 5, 2022 and the next update was due no later than July 5, 2022; however, it was not completed at the time of the inspection.
Client #5 was admitted on September 1, 2021 and discharged March 24, 2022. A treatment plan update was completed on November 8, 2021 and the next update was due no later than January 18, 2022; however, no update was completed.
Client #6 was admitted on October 28, 2021 and discharged on April 28, 2022. A treatment plan update was completed on November 18, 2021 and the next update was due no later than January 18, 2022; however, it was completed on February 9 2022.
Client #7 was admitted on December 27, 2021 and discharged March 31, 2022. A treatment plan was completed on January 7, 2022 and the next update was due no later than March 7, 2022; however, no update was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The OP Director or the D&A Supervisor will provide the therapist will be provided end dates for treatment plans and provided a list of consumer's on their caseload with treatment plan update dates. They will be provided this on a monthly basis. The OP Director or D&A Supervisor will follow up with the therapist in regards to the treatment plan updates. |