| 6400.112(d) | The sleep fire drills that occurred on 10/8/2020 (7 min), 10/30/20 (5min, 40sec), and 10/31/20 (6min, 20sec), were all unsuccessful in getting individuals evacuated under 2.5 minutes. An extended evacuation time was not approved by the local fire department until 11/04/2020.
(recommendation: the first fire drill for the month occurred on 10/8/2020 and a second attempt was not completed until the end of the month on 10/30/2020. Had they retried the attempts sooner, they could have resolved the issue within the month. Try reattempts sooner and not at the same times. All 3 were attempted at 11pm. They need to make sure all attempts occur on different days and at different times). | 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. | PROVIDER PLAN OF CORRECTION
DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING.
1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY:
Hope Enterprises will perform an unannounced fire drill on a different day of the week and at a different time of the day or night than the most recently performed fire drill. If the drill is unsuccessful, Hope Enterprises will reattempt the drill within 3 business days. Hope Enterprises will ensure the licensed home has an updated extended evacuation letter written by a fire safety expert who is not a Hope employee by 11/4/2021.
2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS:
Hope Enterprises will inspect all licensed 6400 facilities¿ fire drill records to verify that 1) all unannounced fire drills were successful in evacuation within 2 ½ minutes or the time period specified in writing within the past year by a fire safety expert, 2) fire drills were held on different days of the week and at different times of the day and night, and 3) extended evacuation letters, if necessary, were written within the past year by a fire safety expert who is not a Hope employee. If either element 1 or 2 is not met, Hope Enterprises will immediately reattempt an unannounced fire drill on a different day of the week and at a different time of the day or night than the most recently performed fire drill. If the drill is unsuccessful, Hope Enterprises will reattempt the drill within 3 business days. If element 3 is not met, Hope Enterprises will immediately obtain an extended evacuation letter written by a fire safety expert who is not a Hope employee. Documentation will be available for on¿site review.
3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR:
Hope Enterprises will retrain all staff that 1) unannounced fire drills require evacuation times to be less than 2 ½ minutes or the time period specified in writing within the past year by a fire safety expert who is not a Hope employee, 2) unannounced fire drills must be held on different days of the week and at different times of the day and night, 3) unsuccessful drills must be reattempted within 3 business days, and 4) extended evacuation letters, if necessary, must be written within the past year by a fire safety expert who is not a Hope employee. Hope Enterprises will update its policies to include all four of the above requirements to ensure staff and individuals are prepared to evacuate quickly, safely and efficiently in the event of a real fire. Documentation will be available for on-site review. |
05/31/2021
| Implemented |