Observations
Based on a review of administrative documentation and incident reports, the facility failed to submit an unusual incident report to the Department as required.
Documentation showed an event requiring police presence at the facility on April 2, 2022. This incident was not reported to the Department.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
As of 6/10/22, the regional project director has issued an instructional memo by email to agency staff and the QI director regarding incident reports. A current copy of the incident report procedures has also been sent by email on 6/10/22. The memo states that when an incident of any type happens, the staff who witnesses or is involved in the incident shall notify the program director, the immediate supervisor and QI director by email within 1 hour of the incident. Once notified, the program director will review the reported incident and will then be responsible for ensure that the incident report is filed within 24 hours to all the external sources (DDAP Funding sources SCA). Once notified, the QI director shall review the reported incident and will then be responsible to verify that the incident report has been filed to all the external sources (DDAP Funding sources SCA) by the program director. Any occurrence of an incident report not being filed by a program director shall be addressed by the QI director and shall be corrected within 24 hours. The system of having the QI Director verify incident reporting in real time will be ongoing. |