Observations
Based on a review of client records and other administrative documentation, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that a physical assault occurred on October 28, 2024. The facility submitted a written report pertaining to an incident that happened on October 28, 2024, but it did not contain information about the physical assault that occurred during that incident.
This finding was reviewed with facility staff.
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Plan of Correction
CEO reviewed DDAP 709.34, Reporting of unusual incidents on 4/19/2024. CEO reviewed this report with management on 4/19/2024 to train on reporting of unusual incidents. Clinical director will meet with clinical staff on 5/1/2024 to train on reporting of unusual incidents and documentation to include providing reports of unusual incidents that are complete, consistent, timely, and how to state the facts. Clinical assistant supervisor will meet with clinical assistant staff on 04/29/2024 to train on reporting of unusual incidents and documentation to include providing reports of unusual incidents that are complete, consistent, timely, and how to state the facts. CFO will meet with admin staff on 5/1/2024 to train on reporting of unusual incidents and documentation to include providing reports of unusual incidents that are complete, consistent, timely, and how to state the facts. Unusual incidents will be reviewed quarterly with Arc Manor Evaluation and Monitoring Committee. |