Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings include:
Fire drill records from March 2011 through February 2012 were reviewed on March 14, 2012. Sleeping hours at the facility are from 11:00 PM until 6:45 AM. The facility conducted fire drills during sleeping hours on the following dates: November 19, 2011 and December 17, 2011. Based on the fire drill records reviewed, the facility was due to complete a fire drill during sleeping hours no later than May 19, 2011. The facility failed to document a fire drill during sleeping hours at least every six months.
The project/facility director was interviewed on March 14, 2012 at approximately 2:30 PM and confirmed the findings.
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Plan of Correction
This facility shall conduct a fire drill at least once every six months during resident sleeping hours. The Administrative Secretary will maintain written documentation to insure that this non-compliance issue is corrected. The Institutional Services Director shall continue to review and sign-off on all monthly fire drills and track at least one fire drill to be conducted every six months during resident sleeping hours. |