Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The facility has an exception to the Department of Drug and Alcohol's physical plant standards for Nonresidential Facilities, Chapter 705.28(d) (7), relative to activating a fire alarm or smoke detector during a fire drill. The exception states: The fire alarm will not be activated during fire drills, documentation that the alarm system is in working order needs to be available for review during licensing inspections. This documentation must be updated on an annual basis.
The facility failed to comply with an exception granted by the Department, relative to Chapter 705.28(d) (7) that required the facility to provide annual documentation that the alarm system is in working order.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager will obtain facility documentation that the fire alarm is in working order no later than 5/8/2015. Moving forward the Program Manager will obtain facility documentation yearly to ensure fire alarms are in working order and conduct monthly fire drills as required. |