| 6400.112(c) | The written fire drill records for the fire drills held on 6/28/18, 7/26/18, 9/28/18, 10/27/18, 12/16/18, 3/20/19, 5/15/19 do not address problems encountered; this section was left blank. | 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. | Historically, we have instructed staff to document on the fire drill only if there was a problem encountered. If nothing occurred, there would be no documentation in this section. This has been our process for many years. It has not been discussed with us during any previous licensing inspection that we were not meeting the regulation or that we needed to consider making any changes. This would have been greatly appreciated, as we always value the guidance received during inspections and have made adjustments as needed.
Going forward, all staff at all homes will be instructed to document ¿none¿ under ¿Problems Encountered¿ if there is no occurrence to be documented. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19.
We will continue our current fire drill review process with an emphasis on no part of the documentation being left blank. The Supervisor of each home will review the Fire Drill to ensure that staff running the drill has completed the documentation in its entirety. The Supervisor will present the drill to the Specialist, who will also review the drill for accuracy and completion. The drill will then be submitted to the next reviewer, who will do the same. The Associate Director, Community Living will then complete a final review of the drill before filing. |
07/31/2019
| Implemented |