Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once per month.
The fire drill logs for the period of January - December 2021 were reviewed. There was no documentation of a fire drill conducted during February 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsibility for running monthly fire drills has been re-assigned to a different staff member, the Program Administrative Assistant, who is on-site daily as of 09/01/2021. Fire Drill Logs will be kept for at least one drill per month as required. All other occurrences of the Fire Alarm going off will also be documented. This procedure was again reviewed with the Program Administrative Assistant on 2/17/22. The Program Administrative Assistant will be facilitating the monthly fire drills, as well as documenting that they are occurring. The Facility Director will ensure that a monthly fire drill has occurred prior to the end of each month and that it has been properly documented. |