Observations
The facility failed to document the fire alarm and/or smoke detector was set off during each fire drill.
The facility has been licensed since August 10, 2016. The fire drills for the period of August 2016 to present were reviewed on November 3, 2016. None of the fire drills conducted during that period indicated the fire alarm and/or smoke detector were set off during the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will implement a new fire drill log that has all the required fire drill information including which fire alarm was set off or pulled. This form will be implemented December 2016.
Program Director will review the Fire Drill log and fire drill requirements with all staff by 12/8/2016. |