INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Community Service Foundation, 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:
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Plan of Correction
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on the review of the facility's unusual incident policy and procedure on January 3, 2018, the facility failed to develop and implement policies and procedures that included:
(1) Implementation of a timely and appropriate corrective action plan, when indicated.
(2) Ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy that specifically states the reporting of unusual incidents as outlined in 709.34 (a) is being revised by the Project Director and/or Facility Director with Quality Assurance Committee to be presented to the board of directors for approval at the next board meeting in Spring 2018. We will submit the board of directors approved POC by April 30, 2018 to DDAP. |