| 6400.103 | The written evacuation procedure for the home did not include the means of transportation to the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Associate Director of Operations developed a standardized Written Emergency Evacuation Procedure template that includes Individual and Staff responsibilities, Means of Transportation, and an Emergency Shelter location on 8/13/21. All Program Managers shall implement the standardized template within their program and update it to include all necessary and current information for the Individuals residing in that program by 10/8/21. |
09/23/2021
| Implemented |
| 6400.112(c) | The specific information required in 6400.112c to document for fire drills was not recorded and completed at the time of the drill. It is unknown if the information recorded for fire drills on 9/25/20, 10/31/20, 11/2/20, 12/8/20, 3/19/21, 5/19/21, 6/17/21, and 7/9/21 was accurate information as the information was not recorded until a few days or even weeks after each fire drill was held. | 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. | All homes to complete an August 2021 fire drill, post Licensing, by August 25th and
submit form within one hour of completing drill. Associate Director of Operations updated Friendship Community policy to require completion of Fire Drill Record within one hour of completing the drill, and provide training on updated expectations to Program Managers and Program Coordinators on 8/20/21. |
09/23/2021
| Implemented |