Observations
Based off of a review of facility records, the facility failed to complete a fire drill during sleeping hours at least every six months.
Fire drill logs provided by the facility documented a fire drill occurring on December 1, 2022 at 5:30am. The next fire drill during sleeping hours was due to be completed no later than June 1, 2023. The facility fire drill logs did not document any further fire drills conducted during sleeping hours. Fire drills were reviewed from November, 2022 through August, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/1/2023, the Executive Regional Director of Inpatient Services will re-educate all applicable staff on the regulation pertaining to fire drills. The Executive Director of Inpatient Services will implement fire drills to rotate each month so that every quarter will include all 3 shifts. These will be scheduled on the appropriate staff's calendar to ensure they are completed by their due dates.
The fire drills will be audited and reported at the monthly Health & Safety Committee.
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