Observations
Based on a review of the facility's October 2024 through September 2025 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday through Thursday 8:30 am to 7:00 pm and Friday 8:30 am to 5:00 pm. Every fire drill completed during the reviewed period was conducted prior to 9:30 a.m. None of the fire drills were conducted during the afternoon or evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager developed a revised Fire Drill Schedule for the program on 11/6/2025 to ensure drills occur on different days of the week, at varying times of the day, and across all staffing shifts (Mornings, afternoon and evenings). The schedule will only be available to the Program Director and Operations Manager responsible for holding the drills. Completion: 11.6.25
Beginning in November 2025, the updated 12-month fire drill schedule will be implemented. Staff will document the drill on the Fire Drill Log Form and send the completed form to the Operations Manager for review. Completion: 11.30.25
The Operations Manager will continue to maintain all Fire Drill logs and review each completed Fire Drill Log Forms monthly for completion and accuracy to ensure they meet regulatory requirements. If any issues are found on the form, the Operations Manager will send the form back to staff to be corrected or the fire drill will be conducted again. Completion: 12.1.25 |