Observations
Based on a review of the facility fire drill log for the months of May 2022 through January 2023, the facility failed to provide documentation of a fire drill being conducted the month of December 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief executive director reviewed with senior management team (Clinical director, CFO, and lead supervisors) regarding the requirement that an unannounced fire drill shall be conducted every month. This was reviewed at the safety meeting on 2.28.23 with safety department lead committee member and senior clinical assistant. The safety department lead committee member and senior clinical assistant will plan unannounced fire drills for the whole calendar year. A fire drill will be conducted by the senior clinical assistant or a designee for the safety department committee. A completed fire drill report will be reviewed monthly at every safety department meeting on the last Tuesday of every month. The annual safety training which will review procedures for all fire drills will be reviewed at clinical meeting on 3.9.23 with all clinical staff and will be reviewed at the clinical assistant meeting on 3.28.23 with all support staff. This will also be reviewed at integration meeting on 3.7.23 with COO and administrative staff. |