INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County, Inc. 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.
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Plan of Correction
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and implement policies and procedures to respond unusual incidents. The policy and procedure presented does not include all of the incidents included in 709.34.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director will review regulation 709.34 and update the facilities current policy and procedure for unusual incidents and add physical assault or sexual assault by staff or a client. Director will complete this updated policy by 6-9-17 and train staff on this updated policy and procedure by 6-14-17. Director and or clinical supervisor will review the need for updated policy and procedure at least quarterly. |
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.
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Observations
The facility failed to notify the Department within three business days following an unusual incident for a death that occurred in January 2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Director will review regulation 709.34 and update current policy and procedure regarding reporting of unusual incidents. Director will hold a an agency wide training on the procedure of reporting unusual incidents and specifically review that required unusual incidents must be reported to the Department within three business days and not just the funding source by 6-14-17. |