Observations
Based on an administrative review of the May 2023 through December 2023 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
As of the date of the inspection, there were no fire drills conducted during every month reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director will create a yearly fire drill schedule beginning in January 2024 and update the schedule yearly. Identified fire drill log forms will be utilized to document monthly fire drills. Office manager will oversee the fire drill schedule and ensure that fire drills are conducted monthly as scheduled. |