Observations
Facility Policy and Procedure manual was reviewed during a licening inspection on June 28, 2016 and was found not to be in compliance with 709.34 Reporting of unusual incidents.
Facility policy failed to include the reporting of the reporting of unusual incidents as per 709.34, subsection (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:
(1) Physical or sexual assault by staff or a client.
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
(5) Outbreak of a contagious disease requiring CDC notification.
This information was reviewed with facility staff.
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Plan of Correction
The policy on reporting of unusual incidents as per 709.34 (c) has been developed and implemented by the Milestone Rehabilitation effective 07/18/2016.
The Project Director will responsible for the compliance with the policy 709.34 - Reporting of unusual incidents.
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