HospitalInspections.org

Based on a review of facility documents, and staff interviews (EMP), it was determined that the facility failed to conduct quarterly fire drills at their provider-based satellites.

Findings:

Review of the facility's policy entitled "Emergency Preparedness Management Plan," reviewed July 2014, "... The purpose of the Emergency Preparedness Management Plan is to establish and maintain a Plan to ensure an effective response to disasters or emergencies affecting the environment of care ... This Plan ... shall cover all areas owned or leased by the hospital ... ."

Review of "Windber Medical Center Department Policies and Procedures Subject: Off Site Fire Drills/Evacuation Plan ... Policy 1. All off site personnel will be trained to participate in quaterly fire drills at their scheduled locations. ..."

1. A review of hospital owned off site satellites locations (locations 1-4) fire drills log, it was revealed that only one fire drill was conducted on November 5, 2018, at all four locations during the calendar year of 2018.

2. EMP5 confirmed the above findings that quarterly drills did not occur.