| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 65C0001001 | (X3) Date Survey Completed 02/08/2019 |
| Name of Provider or Supplier Hafa Adai Specialist Group, Llp | Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| K0712 | Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to conduct fire drills on a quarterly basis as required. Failure to conduct fire drills as required, could result in the failure of the staff to respond quickly and efficiently in the event of a fire. Findings include: On January 31, 2019, at approximately 2PM the office manager was asked to provide records of fire drills held during 2018. Review of these documents showed that the facility held fire drills on October 18, 2018 and February 12, 2018. No fire drills were conducted during the second quarter of 2018 (April-June) and the third quarter in 2018 (July-September). The office manager confirmed that the only fire drills conducted in 2018 were held in February and October. This could affect all staff and patients. |