Observations
Based on a review of incident reports, the facility failed to inform the Department of unusual incidents within the required 3 business days. Incidents occurred on 3/27/22, 3/28/22 and 4/18/22 that required the presence of ambulance personnel at the facility to transport clients to the hospital.
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Plan of Correction
LO362
§709.34. Reporting of unusual incidents.
This facility has developed policy's and procedure's that specify if the police, fire and/or ambulance personnel show up, an incident report will be completed and submitted to DDAP within 3 business days.
The reports have been submitted to DDAP and that was done on 5/11/2022.
The Facility Executive Director will be responsible ensuring the corrective action(s) is implemented when an incident occurs, keeping a record of the incident reports and forwarding all incident reports to the appropriate reporting agencies, as well as monitoring the corrective plan of action.
This plan of correction will take place on 5/11/2022. |