Observations
Based on a review of the facility's January 2019 through January 2021 fire drill log, the facility failed to conduct unannounced fire drills at least once a month for the months of March 2020 through July 2020 and November 2020 through January 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The TASC Executive Director addressed the requirement to complete monthly, random fire drills with the TASC supervisors. Each supervisor and the Executive Director have been assigned the responsibility of conducting two unannounced fire drills per year. A tracking sheet was devised and stored in a central location for all supervisors to access during their assigned month. Information to be collected includes the month, day, date, time, duration of the drill, number of clients and employees evacuated, type of alarm, evacuation route, and evacuation assembly point. All supervisors have familiarity with this form and with facilitating fire drills. The change was made effective on March 1, 2021. The Executive Director will sign off on the form that each fire drill has been completed appropriately. In addition, the Executive Director understands that he should have requested an exception from this requirement during the pandemic. |