Observations
Based on a review of fire drill records, the facility failed to repair inoperable fire alarms, as required.
The findings include;
In the review of the written fire drill records from 09/30/2010 through 08/30/2011, documentation stated that the fire alarms failed to work for the January , February, March, and May 2011 fire drills. An interview with the facility director confirmed that the alarms failed to work. The facility's documented response to the inoperable fire alarm indicated contact was made for repair service. The facility failed to have documentation of these repairs and drills were conducted for several months with an inoperable fire alarm.
|
Plan of Correction
A new Fire Drill Log was created by the Program Director and put in effect on 10/7/2011. The Log includes an added component and responsibility for the staff person performing the inoperable fire drill to call ADT/Simplex, the monitoring company, and request service within 24 hrs. It also instructs staff to inform the Program Director within 24 hours of the inoperable alarm. ADT/Simplex will call the Program Director or vice verse within 24 hours to schedule repair. Service will be scheduled within 48 hours from the date of the inoperable date of the fire drill according to state regulations. Repair bills and other supportive documentation will be attached to the Fire Drill Log kept in the first floor hallway in order for records to be self contained accessible. |