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.
Client records were reviewed on January 25, 2017. The period of February 2016 - January 2017 was reviewed. During that time period, three clients were found to have died while active in treatment. No unusual incident reports were sent to the Department for any of the client deaths.
Client #11 was admitted on 9/29/16 and discharged on 11/15/16 due to death.
Client #12 was admitted on 5/24/16 and discharged on 7/12/16 due to death.
Client #13 was admitted on 11/18/15 and discharged on 4/1/16 due to death.
The findings were discussed with facility staff throughout the licensing inspection.
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Plan of Correction
In reference to licensing standard 709.4 (c) (1) ? Reporting of unusual incidents the Leadership of NHTC (Facility Director and Project Director) are addressing the identified deficiency as follows:
1. All staff (5 clinicians) have been provided clarification of how this regulation applies to patients in an outpatient setting and the expectations of Leadership going forward from this date.
2. If any staff member is notified, or receives second-hand knowledge that a patient has died, that staff must report said unusual incident to Facility Director within 24 hours.
3. All staff were given a copy of NHTC P&P Manual: Emergency Plans and Procedures (14) (a-b) ? pgs 97-98, which provides protocol for handling this type of incident, with specific action steps for staff clearly identified. This procedure was reviewed with each employee to ensure comprehension.
4. As documented in the above P&P, the Project Director will attempt to confirm the status of the patient as "deceased". Thereafter the Project Director will complete and submit "Unusual Incident" report to DDAP within 72 hours of death notification.
5. This protocol was added to orientation package provided to, and reviewed with, all new employees and/or volunteers of NHTC.
6. Leadership will ensure adherence to this protocol effective immediately.
7. Project Director will monitor adherence to this standard and consult with Facility Director as appropriate to comply.
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