Observations
The facility failed to document a fire drill during sleeping hours at least every 6 months based on a review of July 2016 - June 2017 fire drill records during the annual licensing inspection conducted on July 20, 2017.
Fire drills during sleeping hours were only conducted in July 2016, August 2016 and June 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In conversation with the property manager we discovered that the fire drill during sleep hours that would have put us in compliance had been cancelled by them as there was a drill completed during the month when a fire alarm was triggered elsewhere in the building during that month. It was reinforced that in the future no fire drills during sleeping hours should be cancelled for any reasons. Additionally, the Life Skills Supervisor who receives the fire drill schedule for the year from the property manager will track the drills to ensure that the drills during sleep hours are completed as scheduled and at least every 6 months. |