Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill. The findings include: Fire drill logs were reviewed on January 8th, 2015. Fire drill documentation was reviewed from December 2013 through December 2014. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the fire drills. This documentation was missing on all fire drills that were reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff received a memo regarding the procedure and documentation of agency fire drills from the Executive Director on January 16, 2015. Program Supervisors of each department were instructed to provide follow up instruction and training to all staff in the January or February department staffing meetings.
Clerical staff in each office are responsible for initiating and documenting monthly fire drills except in Emporium where the assigned treatment staff are responsible. At Maple Manor the supervisor will assign a staff to conduct the monthly fire drill depending on the time of day or night when the drill will take place.
Fire drills must be completed between the first day and the tenth day of each month. All staff and clients who are in the office at time of monthly fire drill are required to participate.
Fire drills may not be announced ahead of time. However, the staff person in charge will notify ALL staff and clients in the office that a practice fire drill is going to take place just prior to sounding the fire alarm or smoke detector.
The smoke detector alarm and fire alarm must be set off at each check and documented on the fire drill sheet. The Bradford office and Maple Manor are exempt from sounding alarms during practice fire drills due to having an approved exception from the state as a result of having a shared alarm system involving other tenants in the building. These two offices are still required to have their alarms checked and documented twice per year. These checks must be completed between the first and tenth of July and December each year. The designated person in Bradford and at Maple Manor will clear this with the landlord.
Fire drill sheets must be either scanned and emailed or faxed to the administrative office to the attention of the clerical supervisor by the 20th of each month. The Executive Director and the Clerical supervisor will review the fire drill sheets to ensure that drills are occurring at each location each month and that they are being documented appropriately. The Clerical Supervisor will utilize a spreadsheet to track the monthly fire drills at each facility location.
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