INITIAL COMMENTS
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This report is a result of an on-site and off-site complaint investigation conducted on November 4, 2021 through November 18, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of progress notes and unusual incidents on November 4, 2021, the facility failed to submit an unusual incident when there is a client's death. Client's death May 20, 2017The finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On December 17, 2021, the Program Director reviewed the Event Reporting System information and learned the correct procedure to follow when submitting Unusual Incident Reports following an unusual incident report involving death or serious injury due to trauma, suicide, medication error, or unusual circumstances. To ensure compliance with states guidelines and regulations, the Program Director will complete necessary documentation pertaining to a client's death, using the patient's first name and last initial or shortkey ID, and will submit the unusual incident form within three (3) calendar days to the Department of Drug and Alcohol using the Event Reporting System. Finally, to ensure ongoing compliance with state regulations, the Program Director will review the Unusual Incident Reporting guidelines once per month to maintain professional development and competency. |
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
Based on a review of progress notes on November 4, 2021, the facility failed to submit an unusual incident when police are on site. Police was on site April 18, 2018The finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On December 17, 2021, the Program Director reviewed the Event Reporting System information and learned the correct procedure to follow when submitting Unusual Incident Reports following an unusual incident involving an event at the facility requiring the presence of police, fire, or ambulance personnel. To ensure compliance with state guidelines and regulations, the Program Director will complete necessary documentation pertaining to the presence of police on site and will submit the unusual incident form within three (3) calendar days to the Department of Drug and Alcohol using the Event Reporting System. Finally, to ensure ongoing compliance with state regulations, the Program Director will review the Unusual Incident Reporting guidelines once per month to maintain professional development and competency. |