Observations
Based on a review of facility records during the onsite inspection conducted on May 18, 2016, the facility failed to activate the fire alarm during each fire drill.
The facility's fire drill logs documented that the facility did not activate the fire alarm system for the fire drills conducted on the following dates: 07/29/2015, 8/5/2015, 9/1/2015, 10/19/2015, 10/29/2015, 11/24/2015, 12/17/2015, 12/21/2015, 1/4/2016, 1/28/2016, 2/25/2016, 3/22/2016, 3/31/2016, 4/14/2016.
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Plan of Correction
On 6-21-2016 a letter was sent to the Department of Drug & Alcohol Programs requesting an excemption to continue to use an in house verbal call system for all fire drills. Staff will verbally call a fire drill twice a month, 1 per shift guiding all occupants in the facility safely out of 1 of 2 designated exits. These drills will be documented monthly on the fire drill grid and reviewed by the Division Director as well as reported monthly in the CQI process and monthly Safety Committee meetings.
Should the exemption not be granted, staff at the facility will take the steps necessary to comply with the regulation as it currently stands. |