Observations
Based on a review of the facility's March 2024 through January 2025 fire drill logs, the facility failed to conduct fire drills at days of the week, at different times of the day, and on different staffing shifts.
The facility's posted hours of operation are Monday 8:00AM to 5:00PM, Tuesday through Thursday 8:00AM to 8:00PM and Friday 8:00AM to 4:00PM. Ten fire drills conducted during the reviewed period were completed during the hours of 8:00AM through 10:00AM and one fire drill was completed at 1:59PM. There were no fire drills conducted during the facility's evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fire drills will be conducted by the OP Supervisor at least one to two times a year, during the evening hours of operation. Also, the OP Supervisor will make sure the times of the drills will be more varied throughout the day shift hours. These drills will happen at least once a month and OP Supervisor will be responsible for maintaining the fire drill log. |