Observations
Based on a review of fire drill logs and a staff interview, the facility failed to conduct fire drills at different times of the day, as required.The findings include:Fire drill logs were reviewed on September 22, 2010. Per regulation, the nonresidential facility shall conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Monthly fire drills were reviewed from October 2009 through September 2010. All fire drills were conducted between 11:40 AM and 12:25 PM. The facility failed to conduct fire drills at different times of the day.The lead counselor was interviewed on September 22, 2010 at approximately 2:30 PM. The lead counselor confirmed that fire drills for the past twelve months were conducted between 11:40 AM and 12:25 PM.
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Plan of Correction
The facility did not conduct required fire drils at various times throughout the treatment day.
In january of each year, the facility Safety Officer will build into the fire drill schedule various times, including during patient dosing hours, for the drills to be conducted.
The Safety Officer will provide the fire drill schedule to the facility Director in order to insure that the drills are conducted at different times during the course of a year.
The Facility Director is responsible for ongoing compliance in this area. |