Observations
Based on a review of the facilities fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
On November 9, 2011, the fire drill logs were reviewed covering the period from December 2010 through October 2011.
The facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The facility documented fire drills during sleeping hours on January 25, 2011 and August 10, 2011.
The findings were reviewed with the facility director during the inspection and during the exit interview.
The facility was not able to provide further documentation, and therefore did not dispute the findings.
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Plan of Correction
The Facility Director will coordinate the scheduling of a fire drill during sleeping hours at least every six months with the Director of Maintenance. A Fire Drill during sleeping hours will be scheduled by no later than January 20, 2012 |