Observations
Based on a review of the facility's January 2026 through July 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation in the fire drill logs indicating an unannounced fire drill was conducted during each of the months of January 2026 through June 2026. The only unannounced fire drill conducted was during the month of July 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
DIBE Arcadia Healthcare Services LLC acknowledges the cited deficiency regarding failure to complete and/or document required monthly unannounced fire drills beginning January 2026.
Upon review, the facility confirmed that only one fire drill was completed and documented prior to the August 2026 inspection, and that drill occurred in July 2026. Required drills for January through June 2026 were not completed and/or documented. Historical drills that were not conducted will not be backdated or recreated.
To correct the deficiency, DIBE has established a formal monthly fire-drill compliance process. The July 2026 drill will remain as the facility documented pre-inspection fire drill. A compliant unannounced fire drill for August 2026 will be conducted no later than August 31, 2026, and at least one unannounced fire drill will be conducted during every calendar month thereafter. A standardized Fire Drill Log will be completed following each drill and retained in the facility Fire Safety / Emergency Preparedness Compliance Binder.
At this present time, the Project Director/CEO is responsible for implementation and continued compliance and will review fire-drill documentation monthly. A designated Facility Administrator/Clinical Director or Compliance Designee will serve as backup. A quarterly internal audit will verify completion and documentation of each monthly drill.
Any deficiency identified during a drill or audit will be corrected promptly and documented.
All applicable staff will be re-educated regarding DDAP fire-drill and emergency-response requirements by Sept. 10th, 2026. New employees will receive fire-safety training during orientation. Corrective Action / Full Compliance Date: Sept 10th, 2026. Ongoing monitoring will continue monthly and quarterly thereafter.
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