Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month as required by regulation.
The findings include:
The fire drill logs were reviewed on September 16, 2015. There was no documentation of unannounced fire drills for the months of November 2014 and February 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of this deficiency the following has been addressed to maintain compliance in the future:
Findings review with on-site RISK liaison and lead counseling staff to ensure a systems of checks and balances with implementing and documenting fire drills according to regulations.
Process and documentation review with staff on each shift who is responsible for leading drill.
Monthly submission process to Program Director of fire drill documentation to ensure frequency and documentation is maintained.
Monthly staff meeting review through RISK agenda items. |