Observations
Based on a review of fire drill records, the facility failed to evacuate the building during unannounced monthly fire drills.
The findings include:
Fire drill records were reviewed from December 2011 through November 2012. The facility failed to evacuate the building during unannounced monthly fire drills from April 2012 through November 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the facility did not evacuate the building during these fire drills.
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Plan of Correction
Facility 117021 will evacuate the building during the unannounced monthly fire drills. The facility director will be responsible for re-education of staff on the fire drill procedure. The facility director will file a request for exception to the regulation of evacuation of the building. The request will be to exit to a 2 hour fire barrier which is the facility's current policy. |