INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, SPHS Behvioral Health 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 (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
The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the death of a client for client records reviewed on January 30, 2018.
Client # 9 was discharged from the facility on October 20, 2017 due to the death of the client. Cause unknown. There was no documentation provided that an unusual incident report was sent to the Department as of January 30, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisors and the Clinical Director collaborated on the procedure for unusual incident report submission. The administrative team (Monessen Outpatient Supervisors and Clinical Director) decided that all unusual incidents must be reported to the Program Supervisors immediately upon receipt of such information. The Program Supervisors will then determine the need for an unusual incident report, and they will also be responsible for ensuring the report is submitted by staff who received the information within 3 business days. This procedure will be reviewed with staff during the next Drug and Alcohol Clinical meeting set to occur on February 16, 2018. The unusual incident report procedure will be explained extensively at the mandatory staff meeting which is scheduled for February 21, 2018. |