705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's May 2024 through May 2025 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The August 21, 2024 fire drill log did not include documentation of the amount of time for evacuation. Additionally, the September 19, 2024 fire drill log did not include documentation of the amount of time it took for evacuation and the number of persons in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Facility failed to maintain a complete written fire drill record. The August 21, 2024 fire drill did not include documentation of the amount of time taken for evacuation and did not include the number of persons in the facility at the time of the drill.
Action: The Plant Operations Manager will be responsible for the auditing of monthly fire drills specifically to insure the log contains the following items: the date, the time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Monitoring: Compliance rates will be reported on during Monthly PI meetings. The compliance rates will be monitored by the PI committee until 100% compliance has been reached for 6 months. |