Observations
Based on a review of administrative records and staff interview, the facility failed to conduct unannounced fire drills at least once a month.
Fire drill records were reviewed from September 2023 to June 2024. The facility did not conduct a fire drill between the months of December 2023 and April 2024.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
It shall be the responsibility of the Administrative Support Coordinator, under the supervision of the Program Manager to complete and record monthly unannounced Facility fire drills.
The Program Manager is responsible for monthly checks of the fire drill log. |