| 6400.112(c) | The fire drill record for the fire drill held 4/4/18 at 10:30PM did not include the 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. | As a result of the deficiency, the Fire Drill Record form was revised to highlight the amount of time it takes to evacuate; this includes a line for minutes and a line for seconds. The program managers were provided with training regarding the revised form and the regulation. Furthermore, records for other sites were inspected for compliance in this area to ensure there are no other deficiency.All training will be completed and submitted to ODP for review by 11/15/2018. [At least quarterly for at least 1 year, a designated staff person trained in the requirements of written fire drill records shall audit all written fire drill records to ensure all fire drills are conducted and documented as required. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 11/9/18)] |
11/15/2018
| Implemented |