Observations
Based on a review of the monthly fire drill evacuation reports on June 27, 2011, the facility failed to document the exit route used.
The findings include:
On June 27, 2011 at 2:30 PM, the monthly fire drill evacuation reports from July 2010 to May 2011 were reviewed. The time frame for the review of the fire drill evacuation reports was from the date of the last survey until June 2011. This was an eleven month period. The documentation for four of the eleven months did not include the exit route used. The reports which did not document the exit route used were September 29, 2010, October 27, 2010, November 17, 2010, and February 15, 2011.
This was discussed and confirmed with the clinical supervisor on June 27, 2011.
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Plan of Correction
Program Director of Outpatient will generate a new fire drill form to include exit route. This form will be reviewed at the weekly staff meeting by 7/22/11. This will be reviewed and followed up on by the Division Director via monthly QI meetings.
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