6400.112(c) | The written fire drill records for fire drills held on 12/14/17 and 8/20/17 did not include the amount of time it took for evacuation. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On May 22, 2018 all House Managers, Clinical Director, Clinical Supervisor and the Program Director reviewed the 6400.112 requirements. Fire drills were conducted the week of May 28, 2018 through June 1, 2018.
In services for all staff were held May 23, 29,30, June 1,4,6,8 to review the record of fire drill and fire equipment checks. An example was used for staff to complete the form in its entirety. When the fire drill and Fire equipment check is completed after each fire drill, it is to be submitted to their supervisor by the next business day. The House manager will review the form to assure compliance to the regulation. The house manager will verify that the form is complete and accurate by signing and dating the form. It is then given to the Clinical Director who reviews and approves it by signing and dating the form.
Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur.
Effective Date: June 1, 2018
Responsible Party: Program Director, House Manager, Compliance Officer
[Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (AS 6/21/18)] |
06/01/2018
| Implemented |