Observations
Based on a review of the fire drill record log, the facility failed to document fire drills at least once a month.
The findings include:
The fire drill record log was reviewed on February 1, 2012. The log was reviewed from the time period covering January 2011 to December 2011. There was no documentation that a fire drill had been conducted for February 2011.
The missing fire drill had been reviewed and confirmed with the clinical supervisor and facility director.
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Plan of Correction
The fire drill schedule is unannounced to all staff except the Program Director, the Program Director's Aministrative Assistant, and the Administrative Clinic Coordinator. The Administrative Assistant lists scheduled monthly dates at random times to ensure all staff and patients are prepared. This fire drill schedule is kept in the Fire Log book. At the time of implementation, emergency fire drills are announced through the telephone emergency system. The Program Director and Administrative Assistant will review the monthly schedule the first working day of the month and then again during the last full working week of the month to ensure the drill was executed and documented. All fire drills are documented, including areas of improvement, in on the Family Center Record of Fire Drill form and kep in the Fire Log book.
Person(s) responsible:Program Director Aministratic Clinic Coordinator, and Administrative Assistant
Timeframe for correction: Immediate
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