INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc. Moffett House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to submit a written unusual incident report with the Department within 3 business days for an event the required the presence of the fire department.
On August 10, 2016 the fire department was dispatched to the facility as a result of smoke on the floor of the facility. The facility had not submitted an unusual incident report as of September 21, 2016.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director reviewed unusual incident policy with Moffett house manager on 9/29/2016. Moffett house manager will discuss unusual incident reporting policy with all staff, during next staff meeting.
The clinical manager or facility director will be responsible for submitting unusual incident report within 3 business day time frame.
Gateway uses an electronic alert system (D3 Security). All fire drills are recorded and monitored by director and GRC's compliance department. The director will receive an email of recorded incidents. This will assist in making sure that unusual incident report in completed in timely manner. |