Observations
Based on a review of fire drill logs, the facility failed to document fire drills at least once a month.
There was no fire drill log documented for March 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the November 16, 2021 annual licensing inspection.
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Plan of Correction
Due to assigned staff failing to ensure that fire drills were completed each month, the clinical supervisor created a yearly schedule for the fire drills to be completed starting in November 2022 through December 2023. The schedule was passed along to those in charge of completing the fire drills, with 3 fire drills scheduled for each month, alternating the exit used, the shifts completing the fire drill, and the time of the fire drills to be completed. |