Observations
The facility failed to conduct unannounced fire drills at least once a month.
The fire drill logs were reviewed on October 22, 2019. The fire drill logs were reviewed for the period of November 2018 - September 2019. There was no fire drill conducted for the month of April 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discussion has taken place between Stepping Stones Clinical Supervisor, Facility Director and Meadville Medical Center Facility Engineering management and internal Fire Marshall (who are in charge of holding and maintaining drills within the entire facility and environs.) To prevent omission of any monthly drill in the future, by the 20th of each month the Clinical Supervisor will verify whether or not a monthly drill has been performed in this building and the paperwork logged in at the Stepping Stones program. If a drill has not taken place, the Clinical Supervisor will notify the internal fire marshall and the Facility Engineering manager and ask that a drill be scheduled in the building as soon as possible, and that the paperwork be forwarded to Stepping Stones, which will continue to be logged along with the unit's remote observation forms. The Clinical Supervisor will make sure to monitor that the drill occurs before the end of the month. |