Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 1565(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the facility's fire drill records show that the last fire drill was conducted in March 2019 and the licensee has not been conducting quarterly emergency disaster drills since then, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 04/30/2026 Plan of Correction Administrator stated they will conduct an emergency disaster drill, submit proof to LPA by POC due date, and conduct emergency disaster drills quarterly moving forward.