Observations
Based on a review of administrative documentation, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that there was an event at the facility which required the presence of ambulance personnel on December 4, 2022. The facility had not submitted an unusual incident report to the Department within the regulatory three business days timeframe.
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Plan of Correction
On 1/13/2023, the Director of Operations conducted a training on incident reporting and the proper procedure to submit an incident report as a viewable attachment to the Quality Assurance department to ensure that all incidents that are reportable are submitted to DDAP in real time. The Executive Director and Quality & Compliance Specialist will continue to review incident reports, complete thorough investigations, and submit/report all unusual occurrences to DDAP within 72 hours. |