Observations
Based on an administrative review of the facility's April 2023 through February 2024 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
Each fire drill log reviewed documented the main entrance was used as the sole exit route during the fire drills.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor currently facilitates all fire drills. The Clinical Supervisor will be responsible for making sure they are alternating the exit routes used during fire drills. The Coordinator will then check and ensure compliance when she receives the fire drill reports. The Clinical Supervisor began alternating exit routes in March 2024, based off of the auditor's feedback during the audit. |