Observations
Based on a review of the fire drill log, the facility failed to document a fire drill at least once a month. The findings include: The fire drill record log was reviewed on July 21, 2015. The log was reviewed from July 2014 to June 2015. The facility failed to document a fire drill for the month of October 2014. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program Response:
The facility will maintain a written fire drill record including but not limited to, the date, time, the amount of time it took for the evacuation, the exit route used, the number of persons in the facility at the time of the drill, and if there were any problems encountered during the drill. This log will be reviewed monthly by the Clinic Director and the Facility Safety Officer.
All patients and staff members are oriented to fire safety as part of their initial orientation. This orientation includes explanation of evacuation procedures and proper response to fire and fire alarms. Fire Safety training is included in annual mandatory training for all staff. All staff will be instructed on proper use of fire extinguisher during initial orientation and annually thereafter. The Facility Safety Officer will conduct this training.
All fire drill reports will be reviewed by the facility or local safety and Risk Management/ Safety Committee to identify deficiencies and performance improvement opportunities.
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