705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of fire drill logs from October 2022 through June 2023, the facility failed to document the amount of time it took to evacuate, the exit route used, the number of persons in the facility, problems encounters and whether the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 18, 2023 the facility will adopt a new fire drill log that will include all components of 705.28(4) including date, item, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The Project Director be responsible for ongoing monitoring of compliance with this requirement. Monitoring will occur monthly. Any concerns/deficiencies identified with the completion of the fire drills will be addressed by the Project Director. |