Observations
The facility failed to conduct fire drills during different times of the day for 6 of 25 fire drills reviewed. This non-compliance was discovered based on the review of the February 2017 through January 2019 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with regulation 705.28. Fire safety. (d) Fire drills. The non-residential facility shall: (6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts ? the following plan of correction will be implemented:
To ensure fire drills meet the expectations of the regulation, Clinical Supervisor has assigned a Fire Drill Coordinator and an Alternate Fire Drill Coordinator at each Trehab outpatient program facility; in the case of 36 Public Ave. site, the Lead Counselor is the coordinator and a designated Counselor Assistant (Marcia Borosh) is the alternate coordinator. The coordinator (and alternate coordinator) have been trained about regulation 705.28, the protocol/action steps for completing a fire drill properly (in writing) and have signed a memo indicating understanding of all aspects of the fire drill regulation/protocol.
The coordinator and alternative coordinator have been provided with an updated Fire Drill Log that is specific to the 36 Public Ave. site, that must be used to conduct drills. It entails: 1. The name of the staff person conducting the drill (as assigned by coordinator) 2. The date and time of drill 3. The number or staff members and/or clients present 4. The length of time it took to evacuate the building 5. The exit route used 6. If problems were encountered during evacuation (and who to contact) 7. Indicate if the alarms are operative ? check the "other means of announcing drill," box (a. Maintenance oversees alarms b. Exception request granted for alternate means of announcing drill due to mixed use building/letter from the Department - DDAP on file) 8. Fire Drill Coordinator signature.
The coordinator and alternative coordinator have been provided with monthly calendar sheets for February ? December 2019. In the upper right hand corner of the sheets is a label that provides the coordinator with a place to indicate who assigned the drill(s) ? coordinator or alternate coordinator, and what shift/time of day the drill will be conducted. The coordinator is responsible for scheduling (at minimum) one (1) monthly, unannounced fire drill at different times of day during staffing shifts. It has been suggested that the coordinator rotate shifts on a monthly basis to cover AM and PM drills, by writing the shift/time of day in the upper right hand corner of the monthly calendar in the (specific) space provided labeled SHIFT. For example, if February's drill was completed during the AM shift, March's drill will be completed during the PM shift. The coordinator for the 36 Public Ave. site will check with building maintenance personnel quarterly to ensure alarms have been inspected/maintained and are working properly.
It has been made clear that the goal is to ensure that all staff and clients know how to evacuate the building and to accomplish this, staff-only drills may be conducted at random/different times during the day. It has also been stressed to the coordinator that the schedule of drills is to be kept private and assigned to staff conducting - on the day of the drill. The coordinator will provide the assigned staff person with the Fire Drill Log ? with appropriate parts filled out, such as which exit to use, for example. The coordinator may schedule drills several months ahead using the calendar sheets, but they are not to disclose the drill plan to anyone to safeguard accurate representation of a real fire event. When/if the coordinator is unable to perform these tasks, the alternative coordinator will be asked by the Clinical Supervisor to do so. The coordinator (and alternate coordinator) have been notified that Clinical Supervisor and/or QM Coordinator will randomly inspect Fire Drill Logs and calendar sheets as part of overall quality management oversight of the physical plant.
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