Observations
Based on the review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The fire drill logs was reviewed on September 30, 2014. The fire drills were reviewed for the period of November 2013 to August 2014. There was no documentation of fire drills for the period of December 2013 to July 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction is put in place by new director for fire drills. Since movement in leadership fire drills were conducted August 2014 and September 2014. The director will keep monthly documentation of when unannounced drills should take place to ensure they are happening. One staff member has also been given the task to track fire drills as well to ensure they are not missed. |