| 6400.112(c) | The written fire drill records for fire drills held on 9/4/18 and 10/12/18 did not include the exact time, AM or PM was missing. | 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. | Plan of Correction
6400.112(c) The written fire drill records for fire drills held on 1/4/18 and 6/5/18 did not include the exact time, AM or PM was missing.
What specific change will be made:
A new electronic Fire Drill form has been developed to ensure completion of deficits reported
A Compliance Department and Compliance Team was developed to ensure oversight and compliance.
Who will make the change:
Compliance Department,
Compliance Team (composed of Compliance Department representative, Program Specialist, Administration, and Training Department,
Training Department,
and DSP.
When will the change be made: 2/1/19
How will the change be made:
An electronic Fire Drill form has been developed that requires every question to be completed, including:
The date the drill occurs
The exact time the Fire Drill begins and ends: (a.m. and/or p.m. must be selected before this section can be completed)
Exit route used
Any problems encountered during drill
Operational status of smoke detectors
In the event that the electronic record is not available, a paper Fire Drill record with a checklist prompting specifics listed above as well as other relevant factors will be used.
All agency fire drill records will be reviewed by the Compliance Department weekly for:
Timeliness and completion, including;
Exact time
Hour
Minutes
Seconds
If drill occurred during a.m. or p.m.
If an alternative route can be/was used
The Compliance Team will meet monthly to review the Fire Drill forms/process and to ensure randomness occurs across all areas of the Fire Drill process.
What system have you implemented to make sure that the same violation will not occur again:
Electronic Fire Drill Form
Compliance Department oversight
Compliance Team reviews
What training has been provided to your staff:
The Compliance has reviewed regulation requirements, deficits, and developed corrective action plans
The Training and Compliance Departments have been instructed of required processes.
DCP training is being rolled out agency-wide beginning February 1, 2019 through March 1, 2019 and will be updated during annual training.
|
02/01/2019
| Implemented |