INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 17, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Dunmore Comprehensive Treatment Center, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's incident reports, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on April 18, 2025. The facility received information that a patient had passed away in their home. There is no documentation that this incident was reported to DDAP.
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Plan of Correction
CD will ensure all reportable incidents will be submitted to DDAP within 3 days of incident via submission of online portal. Upon receipt of internal incident report CD will submit unusual incident report on DDAP portal and notate on internal incident report the date and time of submission for tracking purposes. Office manager will review the internal incident reports prior to end of month submission to ensure that the incident has been submitted. In the event that the CD is out of the office the CS will be responsible for completion of unusual incident report submission to DDAP. These incidents will be reviewed monthly at Leadership meetings to ensure processing is working. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's incident reports, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on April 15, 2025. The incident report noted that a patient was transported from the facility to the hospital via an ambulance. There is no documentation that this incident was reported to DDAP.
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Plan of Correction
CD will ensure all reportable incidents will be submitted to DDAP within 3 days of incident via submission of online portal. Upon receipt of internal incident report CD will submit unusual incident report on DDAP portal and notate on internal incident report the date and time of submission for tracking purposes. Office manager will review the internal incident reports prior to end of month submission to ensure that the incident has been submitted. In the event that the CD is out of the office the CS will be responsible for completion of unusual incident report submission to DDAP. These incidents will be reviewed monthly at Leadership meetings to ensure processing is working. |