INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 24, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(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.
|
Observations
The facility failed to file a written unusual report with the Department within 3 business days for incidents involving patient deaths and a medical emergency which required the presence of ambulance personnel. These incidents occurred on July 24, July 28 and July 31, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.34- All unusual incidents that are required to be reported to the Department will be within 3 business days. The Clinical Director is responsible for making sure that reports are filled out completely and sent in. This change was effective in September 14, 2017 upon the transition of current Clinical Director. |