Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills, as required by regulation.
The findings include:
A review of the fire drill logs was conducted on September 28, 2011. The fire drills conducted from November 2010 - August 2011 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility failed to document any alternate exits used during fire drills. The exit routes used during the fire drill were the same for all fire drills.
An interview with the clinical supervisor was conducted on September 28, 2011. It was confirmed that alternate exits were not used for the fire drills as per regulations.
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Plan of Correction
The Director of Outpatient will ensure that the Johnstown office is practicing fire drills once per month and documenting on their fire safety form the exit route they used during that drill. The Johnstown office will alternate which exit route they use each month with no discernible pattern; however, each route will be used 6 times each year. This will begin on 12/1/11 with the fire drills that month. |