Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records for June 2014 through May 2015 were reviewed on May 26, 2015. The facility failed to conduct unannounced fire drills for the months of January 2015 and March 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A schedule for fire drills will be made to encompass requirements. Follow up will occur by the outpatient director to ensure they have occurred each month by the 15th. |