Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months and did not set off an alarm or smoke detector with every fire drill.
The findings include:
The facility's fire drill logs were reviewed on August 27, 2015 as part of an administrative review. The fire drill logs were reviewed for the time period covering August 2014 to August 2015. Drills were conducted during sleeping hours on August 27, 2014 and July 30, 2015. This timeframe exceeded a six month period for sleeping hours drills.
Additionally, the was no documentation in the fire drill log that a fire alarm had been set off for fire drills during October 2014 through February 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will schedule a fire drill to occur during sleeping hours at a minimum of one time every five months. These drills will be unannounced to all clients and staff with the exception of the night shift supervisor and the Facility Director.
These drills will follow the approved policy of informing the local fire department of the test and setting off the fire alarm system during each drill.
The fire drill log will be reviewed by the Facility Director the day following the sleeping hours drill. If there is a need for the fire drill to be repeated, an overnight drill will be conducted the following month to ensure compliance. |