Observations
Based on an interview with the facility director, the facility failed to provide annual documentation that the alarm system is in working order.
The findings include:
The facility has an exception granted by the Department, relative to Chapter 705.28(d) (7) that required the facility to provide annual documentation that the alarm system is in working order. The Licensing Specialist requested to see a copy of the facility's annual documentation that the alarm system is in working order. The facility presented documentation from 10/29/2013 indicating that the alarm system was is working order. However, annual documentation from October 2014 indicating that the alarm system was is working order was not presented for review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will arrange for Emergency Response Associates to inspect the fire alarm system by March 1, 2015. In order to make sure that this does not recur, Clinical Supervisor will contact the building's Property Manager annually by December 1 to make sure that an inspection of the fire alarm is scheduled. If annual inspection is not scheduled by December 1, Clinical Supervisor will invite Property Manage to schedule inspection and follow-up to make sure that inspection was completed. |