Observations
A review of the March 2016 through February 2017 fire drill logs was conducted during the onsite inspection. The facility failed to provide documentation that unannounced fire drills were conducted during the 2016 months of March, April, May, June, July, and September. Additionally, the logs for the months of February 2017, January 2017, December 2016, November 2016, October 2016, and August 2016 failed to include the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new procedure was implemented in 2017 so that fire drills are completed monthly by Facilities staff.
In order to ensure drills are conducted at the required monthly frequency, drills will be completed by the 3rd week of each month and entered into a tracking worksheet by Performance Improvement staff.
A copy of the worksheet will be distributed to Outpatient Director and Performance Improvement Director. The status of all drills will be reviewed prior to the end of each month at the CGRC Environment of Care committee. If a drill has not been completed, the Facilities staff will be instructed to complete the drill as soon as possible prior to the end of the month.
Completion Date 4/25/17
The fire drill form will be revised by the Performance Improvement Director to include evacuation routes and all staff responsible for conducting drills will be trained to document the evacuation route(s) used.
Completion Date 4/25/17
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