6400.112(d) | The fire drill held on 11-10-18 had an evacuation time of 2 minutes and 38 seconds. The home does not have an extended evacuation time specified in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Program Managers and Program Specialist were retrained on the fire drill process. All fire drills will be complete by the 15th of the month. The exists will be alternated and the evacuation time will be under 21/2 minutes to ensure compliance. If the drill is not accurate another drill will be completed by the end of the month to remain in compliance. [NOT ACCEPTABLE, fire drill can not be scheduled for specific days of the month, all fire drills are required to be unannounced. Immediately, the CEO or Designee shall develop a reporting procedure to follow if problems are encountered including when fire drills are not conducted in the required amount of time. Evaluation of problems encountered shall be conducted and addressed by management staff persons within 1 week of the fire drill. Within 60 days of receipt of the plan of correction, the CEO or Designee shall educate all staff persons responsible for conducting, auditing and evaluating fire drills of the requirements of fire drills as per 6400.112(a)-(I) and the procedures to report fire drill when problems are encountered. Documentation of trainings shall be kept. At least quarterly, a designated management staff person shall audit a 25% sample of all fire drill records to ensure fire drills are held and documented and reported as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/4/19)] |
03/18/2019
| Implemented |