Observations
Based on a review of fire drill records from July, 2021 through April 2022, the facility failed to set off a fire alarm or smoke detector during each fire drill. The facility used a verbal staff announcement.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the July 1, 2021 licensing inspection.
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Plan of Correction
Due to the fire alarm system setting off the alarms for all surrounding businesses, a request for a waiver has been submitted to allow for the use of an alternate way of notifying staff and patients of fire drill. Moving forward, facility director, or assigned designee, that is completing the fire drill will utilize a portable fire alarm to notify all staff and patients of a fire drill taking place.
Facility director and all designees responsible for conducting fire drills have been retrained to ensure they know that the portable fire alarm must be used for each fire drill. Facility director will be checking monthly to ensure that each fire drill is completed correctly. |