Observations
The facility failed to prepare alternate exit routes to be used during fire drills.
The fire drill logs were reviewed on January 18, 2017 for the time period of January 2016 - December 2016. All of the fire drills documented in this time frame indicated the same exit route used. There were no alternate exit routes documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The facility has taken steps to correct the deficiency by updating the existing fire drill procedure to reflect that the drills will alternate between the two facility entrances/exits.
- Steps taken by the facility to ensure the deficiency does not recur includes increased monitoring of the use of alternating exits, to support this the Fire Drill Log has been revised to allow tracking of the rotation of the exits utilized for the drill. The exits used will alternate and will be documented by marking the appropriate column on the log, reflecting either the front (glass door) or back (brown door). As of 2/7/17 the facility has conducted a fire drill utilizing the back door and has appropriately documented it.
- Individuals responsible for the implementation of the corrective action plan would include the lead for the fire drills and facility Director. The Fire Drills are typically lead and documented by the Executive Assistant, The Director of Programs and Operations or designee will verify the Fire Drill Logs have been properly completed.
- The procedure has been updated and the log has been revised. The rotation of exits for fire drills and use of the revised log was implemented February 7th. Actions steps have been completed as of the submission date of this plan.
- Deficiency concerns related to the alternating of both exits within the location at 7501 Penn Avenue and the documentation of that rotation being documented appropriately have been addressed.
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