Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on November 17, 2015. The log was reviewed from November 2014 to October 2015. The facility failed to provide documentation of fire drills from November 2014-September 2015.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective October 1, 2015 APM will conduct monthly fire drills at both the mental health clinic at Rising Sun and the Front Street clinic. The fire drills will be facilitated by the Facilities Manager unannounced on different days of the month and at different times of the day. The VP of Health and Clinical Supervisor will participate on a monthly basis to ensure that this practice is maintained. The fire drill log will be maintained at each site by the Clinical Supervisor and reviewed quarterly by Quality Assurance. Compliance reports will be provided to the VP of Health on a monthly basis. |