Observations
Based on a review of administrative documentation, the facility failed to file a written unusual incident report with DDAP within 3 business days following an unusual incident involving a death.
An unusual incident involving a death occurred on June 5, 2026. The facility is a residential facility and is open 7 days per week, 24-hours a day. The facility was required to file a written unusual incident report with DDAP by June 8, 2026. The unusual incident report was filed with DDAP on June 10, 2026.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The delay in reporting was due to waiting for information from law enforcement regarding the final outcome. Sojourner House will not delay the submission of unusual incident reports beyond 3 business days.
Immediate Corrective Actions Completed:
The unusual incident report was submitted to DDAP on June 10, 2026.
Leadership reviewed all unusual incidents from the previous 2 months to ensure no additional reporting deficiencies existed.
The Executive Director and Clinical Leadership Team reviewed DDAP reporting requirements and regulatory expectations.
Effective 6.24.2026:
Staff Training
Action:
Provide mandatory training to all supervisory, clinical, and administrative staff regarding:
DDAP unusual incident reporting requirements.
Regulatory timelines.
Documentation standards.
Escalation procedures for critical incidents.
Training will be incorporated into new employee orientation and annual compliance training.
Responsible Person: Executive Director and Clinical Manager
Completion Date: Within 30 days
Effective: 6/26/2026- A Root Cause Analysis Report will be submitted to DDAP for review.
These corrective actions will ensure that all reportable unusual incidents are identified, documented, reviewed, and submitted to DDAP within required regulatory timeframes, maintaining full compliance with § 709.34(c)(2).
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