D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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GAUDENZIA DRC INC.
3200 HENRY AVENUE
PHILADELPHIA, PA 19129

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Survey conducted on 10/07/2015

INITIAL COMMENTS
This report is a result of an on-site licensure inspection conducted on October 6 - 7, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. 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.	Plan of Correction
705.1 (1) LICENSURE Gen requirements for residential facilities. 705.1. General requirements for residential facilities. The residential facility shall: (1) Hold a license under Chapter 709 (relating to standards for licensure of freestanding treatment facilities) or a certificate under Chapter 711 (relating to standards for certification of treatment activities which are part of a health care facility).
Observations Based on a review of the Residential Aide (RA) log book, the facility failed to ensure that all inpatient residential clients were housed within the licensed floor. The findings include: The inpatient non-hospital drug-free program residential beds for this license are located on the 5th (males) and 7th (females) floors. The 4th and 6th floors are not licensed inpatient residential client floors. The RA log book was reviewed on October 6 - 7, 2015. During the review of the females RA log book, the RA staff members documented that there were inpatient residential female clients housed on non-drug and alcohol floors on the following dates 6/19/15, 6/22/15, 6/23/15/ 6/24/15 and 7/6/15. The RA's documented that one to two clients were housed on the 6th floor. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction The Inpatient Clinical Supervisor will make daily rounds of each floor housing both male and female residents to ensure bed availability. No movement of any resident - both male or female will only authorized without prior approval of the Clinical Supervisor or the Inpatient Director. All residents that were housed on the 4th and 6th floor during the dates 6/19/15, 6/22/15, 6/23/15/ 6/24/15 and 7/6/15 have been discharged.
705.2 (2) LICENSURE Building exterior and grounds. 705.2. Building exterior and grounds. The residential facility shall: (2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
Observations Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The findings include: A physical plant inspection was conducted on October 8, 2015. The facility failed to keep the facility in good repair at all times for the safety and well-being of the residents. Observed in one out of the four shower stalls in the large male bathroom - A porcelain shower tile floor was chipped and extremely damaged; posing a safety hazard for anyone that might use this shower. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction The one damaged porcelain shower tile has been fixed and cemented on 10/19/2015 by Maintenance Staff. Maintenance staff will ensure the shower tiles are clean and safe from hazard by conducting daily checks.
709.28(c) LICENSURE Confidentiality 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
Observations Based on a review of client records, the facility failed to obtain informed and voluntary consent in three out of nineteen client records reviewed. The findings include: Nineteen client records were reviewed on October 6 - 7, 2015. The facility failed to document informed and voluntary consents in three out of nineteen client records, # 2, 3 and 6. Client # 2 - The facility failed to document what was to be release on the consent to release form dated September 22, 2015 for the client's family member. Client # 3 - The facility failed to document what was to be release on the consent to release form dated September 22, 2015 for the client's family member. The facility sent a notice of termination letter to client #6's PO dated September 2, 2015. The letter exceeded 4 PA Code 255.5 by documenting the toxicology results and sending a copy of the toxicology report dated 8/29/15. Additionally, the facility used a lab documented on the client ' s termination letter to the PO, but there was no consent to release documented in client #6 ' s file for this lab. The lab documented on the letter and on the lab report documented Redwood Toxicology. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction The facility will complete the specific information being requested from client records prior to obtaining any client signature for the release the information. Records #2 and #3 will be corrected by the Clinical Supervisor. Client #6 has been D/C?d. The Parole Agent will get the results of clients compliance/progress in the Termination letter , based on the 255.5 regulations. A new release form has been developed for the lab contractor called "Redwood" Lab. This form will be used in conjunction with other release forms that clients sign at intake or for specific other reasons.
709.33(a) LICENSURE Notification of Termination 709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
Observations Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two administratively discharged records. The findings include: Two administrative discharged client records were reviewed on October 6 - 7, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client records, # 6 and 7. Client # 6 was admitted to the facility on July 23, 2015 and administratively discharged on September 2, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection. Client # 7 was admitted to the program on August 5, 2015 and administratively discharged on August 10, 2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project as of the date of the licensing inspection. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction All administrative discharged clients will receive a letter identifying the status of the involuntary commitment discharge decision. This letter will be provided to client prior to leaving the facility, or by mail, depending on client request. A copy will be charted as well, showing proof of this document.
709.52(a) LICENSURE Individual TX and REHAB Plan 709.52. Treatment and rehabilitation services. (a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
Observations Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included type and frequency and/or support services in fourteen out of seventeen records reviewed. The findings include: Seventeen client records were reviewed on October 6 - 7, 2015, for documentation of an individualized treatment and rehabilitation plan. The facility failed to document on the treatment plan the type and frequency of treatment services, and/or support services in fourteen out of seventeen client records, # 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 16, 17, 18 and 19. Client # 1 was admitted to the facility on September 8, 2015. The facility documented the individual treatment plan on September 11, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 2 was admitted to the facility on June 22, 2015. The facility documented the individual treatment plan on June 26, 2015; however, the plan did not include the type and frequency of treatment services to be provided, or documentation of support services. Client # 3 was admitted to the facility on August 31, 2015. The facility documented the individual treatment plan on September 3, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 4 was admitted to the facility on September 11, 2015. The facility documented the individual treatment plan on September 25, 2015; however, the plan did not include the type and frequency of treatment services to be provided, or documentation of support services. Client # 5 was admitted to the facility on September 18, 2015. The facility documented the individual treatment plan on September 28, 2015; however, the plan did not include documentation of supportive services. Client # 8 was admitted to the facility on July 28, 2015. The facility documented the individual treatment plan on August 4, 2015; however, the plan did not include the type and frequency of treatment services to be provided, or documentation of support services. Client # 9 was admitted to the facility on August 31, 2015 and discharged on September 13, 2015. The facility failed to document a treatment plan for client # 9's duration of treatment. Client # 10 was admitted to the facility on July 9, 2015 and discharged on August 21, 2015. The facility failed to document an individual treatment plan for client #10 as of the date of the licensing inspection. Client # 11 was admitted to the facility on August 17, 2015. The facility documented the individual treatment plan on September 20, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 12 was admitted to the facility on August 17, 2015. The facility documented the individual treatment plan on September 24, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 16 was admitted to the facility on August 5, 2015. The facility documented the individual treatment plan on September 4, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 17 was admitted to the facility on August 6, 2015. The facility documented the individual treatment plan on August 20, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 18 was admitted to the facility on July 13, 2015. The facility documented the individual treatment plan on August 15, 2015; however, the plan did not include the type and frequency of treatment services to be provided. Client # 19 was admitted to the facility on June 16, 2015. The facility documented the individual treatment plan on June 18, 2015; however, the plan did not include the type and frequency of treatment services to be provided. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction All individualized treatment plans will include measurable outcome data for services and goals. Type of treatment services will include specific time frame goals such as frequency, duration. To ensure this is completed, the Clinical Supervisor will review this weekly.
709.52(b) LICENSURE TX Plan update 709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
Observations Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in three out of nine records reviewed. The findings include: Nine client records were reviewed on October 6 - 7, 2015, for documentation of treatment and rehabilitation plan updates at least every 30 days. The facility failed to review and update treatment plans at least every 30 days in three out of nine client records, # 3, 17 and 19. Client # 3 was admitted to the facility on August 31, 2015, and was still an active client at the time of inspection. The facility completed the individual treatment plan on September 3, 2015. However, the facility failed to update the treatment plan which was due at least every 30 days or by October 3, 2015. Client # 17 was admitted to the facility on August 6, 2015 and discharged on October 1, 2015. The facility completed the individual treatment plan on August 20, 2015; however the facility failed to update client # 17's treatment plan at least every 30 days or by September 20, 2015. Client # 19 was admitted to the facility on June 16, 2015 and discharged on September 9, 2015. The facility completed the individual treatment plan on June 18, 2015; however the facility failed to update client # 19's treatment plan at least every 30 days or by July 18, 2015 and August 18, 2015. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction Clinical Supervisor will review all treatment plans during supervision bi-weekly, in addition to random auditing of chart weekly to ensure treatment plans are being completed, dated accurately, and signed within a 29 day timeframe.
709.53(a) LICENSURE Complete Client Record 709.53. Client records. (a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
Observations Based on a review of client records, the facility failed to document a complete client record in fourteen out of nineteen client records reviewed. The findings include: Nineteen client records were reviewed on October 6 - 7, 2015. The facility failed to document a complete client's records that included medication records, a record of services provided, progress notes, aftercare plans, discharge summary, and documentation that work done by the client is an integral part of the treatment and rehabilitation plan in client's records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14 and 19. Client # 1 was admitted to the facility on September 8, 2015. The facility failed to document a complete record of services provided to client # 1. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of the service log. In addition, the facility failed to document a complete medication record. Per MAR: Client # 1 was prescribed Risperidone 1 mg on 9/8/15. The facility failed to document whether or not client # 1 received Risperidone 1 mg on September 10, 19, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Sertraline on 9/8/15. The facility failed to document whether or not client # 1 received Sertraline on September 10, 19, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Docusate in the AM on 9/8/15. The facility failed to document whether or not client # 1 received Docusate in the AM on September 10, 19, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Docusate in the PM on 9/8/15. The facility failed to document whether or not client # 1 received Docusate in the PM on September 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Mirtazapine on 9/14/15. The facility failed to document whether or not client # 1 received Docusate in the PM on September 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Risperidone 3 mg on 9/8/15. The facility failed to document whether or not client # 1 received Risperidone 3 mg on September 18, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Folic Acid on 9/8/15. The facility failed to document whether or not client # 1 received Folic Acid on September 10, 20, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Uit. Bl. 100 mg on 9/8/15. The facility failed to document whether or not client # 1 received Uit. Bl. 100 mg on September 10, 20, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Folic Acid on 9/8/15. The facility failed to document whether or not client # 1 received Folic Acid on September 10, 20, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Aspirin 8 mg on 9/8/15. The facility failed to document whether or not client # 1 received Aspirin 8 mg on September 10, 20, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed PM Lactulose 10 gm/30 ml on 9/8/15. The facility failed to document whether or not client # 1 received PM Lactulose 10 gm/30 ml on September 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed Lactulose 10 gm/30 ml HS on 9/8/15. The facility failed to document whether or not client # 1 received Lactulose 10 gm/30 ml HS on September 10, 13, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015. Per MAR: Client # 1 was prescribed AM Lactulose 10 gm/30 ml on 9/8/15. The facility failed to document whether or not client # 1 received AM Lactulose 10 gm/30 ml on September 9, 10, 24, 25, 26, 27, 28, 29 and 30, 2015. Client # 2 was admitted to the facility on June 22, 2015. The facility failed to document a complete record of services provided to client # 2. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record of service log. In addition, the facility failed to document a complete medication record, and documented July and August medications on the same 30 day MAR sheet. Per MAR: Client # 2 was prescribed 1 pill daily of Daily-Vite on 8/18/15. However, the facility inaccurately documented that client # 1 received the medication on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received 1 pill daily of Daily-Vite on August 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Buspirone on 7/15/15. However, the facility inaccurately documented that client # 2 received the medication on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received AM Buspirone on July 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed PM Buspirone on 7/15/15. However, the facility inaccurately documented that client # 2 received the medication on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received PM Buspirone on July 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Famotidine on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2015. The facility did not document whether or not client # 2 received AM Famotidine on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed PM Famotidine on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 2015. The facility did not document whether or not client # 2 received PM Famotidine on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Loratadine on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2015. The facility did not document whether or not client # 2 received AM Loratadine on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed PM Melatonin on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2015. The facility did not document whether or not client # 2 received PM Melatonin on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Lamotrigine on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2015. The facility did not document whether or not client # 2 received AM Lamotrigine on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed PM Lamotrigine on 6/25/15. However, the facility inaccurately documented that client # 2 received the medication on June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 2015. The facility did not document whether or not client # 2 received PM Lamotrigine on June 25, 26, 27, 28, 29, 30, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed Cymbalta on 8/18/15. However, the facility inaccurately documented that client # 2 received the medication on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received Cymbalta on August 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Carbamazepine on 8/18/15. However, the facility inaccurately documented that client # 2 received the medication on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received AM Carbamazepine on August 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed PM Carbamazepine on 8/18/15. However, the facility inaccurately documented that client # 2 received the medication on August 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received PM Carbamazepine on August 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Multi-Vit on 7/22/15. However, the facility inaccurately documented that client # 2 received the medication on August 1, 2, 3, 4, 5, 6, 10, 11, 12, 13, 14, 15, 16 and 17, 2015. The facility did not document whether or not client # 2 received AM Multi-Vit on July 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2015 as prescribed on the MAR sheet. Per MAR: Client # 2 was prescribed AM Motrin 800 MG on July 27, 2015. The facility did not document on the MAR sheet that client # 2 received the medication. Per MAR: Client # 2 was prescribed PM Motrin 800 MG on July 27, 2015. The facility did not document on the MAR sheet that client # 2 received the medication. Per MAR: Client # 2 was prescribed on September 15, 2015, 500 MG of Amoxicillin in the AM which was to be taken until finished. The facility did not document on the MAR sheet that client # 2 received the medication. Per MAR: Client # 2 was prescribed on September 15, 2015, 500 MG of Amoxicillin in the PM which was to be taken until finished. The facility did not document on the MAR sheet that client # 2 received the medication. Client # 3 was admitted to the facility on August 31, 2015. The facility failed to document a complete record of services provided to client # 3. The facility documented sessions on the record of service, but failed to provide DAP progress notes for those services rendered; similarly the facility provided DAP progress notes but failed to document that service on the record. Client # 4 was admitted to the facility on September 11, 2015. The facility failed to document a complete record of services provided to client # 4, specifically documentation of all individual and group sessions received, per review of DAP progress notes. Client # 5 was admitted to the facility on September 18, 2015. The facility failed to document a complete record of services provided to client # 5, specifically documentation of all group sessions received, per review of DAP progress notes. Client # 6 was admitted to the facility on July 23, 2015 and administratively discharged on September 2, 2015. The facility failed to document a complete record of services provided to client # 6, specifically documentation of all group sessions received, per review of DAP progress notes. In addition, the facility failed to document a discharge summary in client record # 6. Client # 7 was admitted to the program on August 5, 2015 and administratively discharged on August 10, 2015. The facility failed to document a complete client record which included a record of services provided, a discharge summary, and documentation that work done by client # 7 is an integral part of the treatment and rehabilitation plan. Client # 8 was admitted to the facility on July 28, 2015. The facility failed to document an aftercare plan and a complete record of services provided to client # 8, specifically documentation of all individual and group sessions received, per review of DAP progress notes. Client # 9 was admitted to the facility on August 31, 2015 and discharged on September 13, 2015. The facility failed to document that work done by client # 9 is an integral part of the treatment and rehabilitation plan. Client # 10 was admitted to the facility on July 9, 2015 and discharged on August 21, 2015. The facility failed to document an aftercare plan and documentation that work done by client # 10 is an integral part of the treatment and rehabilitation plan. Client # 11 was admitted to the facility on August 17, 2015. The facility failed to document a complete record of services provided to client # 11, specifically documentation of all individual and group sessions received. Client # 12 was admitted to the facility on August 17, 2015. The facility failed to document a complete record of services provided to client # 12, specifically documentation of all individual and group sessions received. Client # 14 was admitted to the facility on September 8, 2015. The facility failed to document a complete record of services provided to client # 14, specifically documentation of all individual and group sessions received. Client # 19 was admitted to the facility on June 16, 2015 and discharged on September 9, 2015. The facility failed to document a complete record which included a discharge summary for client # 19. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction the nineteen client records that were reviewed on October 6 - 7, 2015 have been discharged : #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14 and 19. To address this issue moving forward, the clinical supervisor will be responsible for reviewing all client records to ensure all records of service reflect treatment documentation, and the individual sessions. Each primary counselor will be required to provide clinical tracking sheets weekly to the clinical supervisor supporting that all documentation has been completed to reflect these required documents.
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev 709.17. Refusal or revocation of license. (a) The Department may revoke or refuse to issue a license for any of the following reasons: (1) Failure to comply with a directive issued by the Department.
Observations Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents. The findings include: As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on October 6, 2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents. Additionally, the facility failed to report incidents within 3 days per regulation from the time period of June 2015 until October 2015 for incidents involving: 1.Physical or sexual assault by staff or a client. 2.Death or serious injury due to trauma, suicide, medication error or unusual circumstances. 3.Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day. 4.Event at the facility requiring the presence of police, fire or ambulance personnel. 5.Outbreak of a contagious disease requiring CDC notification. The findings were reviewed with facility staff during the licensing inspection.	Plan of Correction The facility has updated the current unusual incident policy to include all DDAP specifications. This was completed during the week of the audit (week ending 10/9/15). The below reporting items are examples of what will be addressed as of 11/16/15.