705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record including the amount of time it took for evacuation and the exit route used.
The findings include:
Fire drill records for November 2011 through October 2012 were reviewed on November 1, 2012. The facility failed to document the amount of time it took for evacuation for the following fire drills: March 24, 2012, July 28, 2012 and August 11, 2012. The facility also failed to document the exit route used during the following fire drills: February 20, 2012, March 24, 2012, June 16,2012, July 28, 2012 and August 11, 2012.
The Unit Manager was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Facility Director reviwed standards and requirements for documenting all elements of a fire drill in the fire drill log for the facility. Effective November 21, 2012 and going forward fire drills conducted at the facility will be conducted monthly and all required elements as outlined in the standards will be docuemnted in the fire drill log maintained by the facility. Unit Manager and Facility Director will monitor for compliance. |