Observations
Based on a review of the facility's internal incident reports on 6/1/2023, the facility failed to report seven unusual incidents to the Department as required.
Documentation showed that ambulance personnel were onsite at the facility on 1/9/23, 1/11/23, 1/14/23, 4/19/23, 4/25/23, 5/9/23, and 5/10/23.
The finding was discussed with facility staff during the complaint investigation.
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Plan of Correction
In lieu of previous RCM leaving position BGB was unaware of reportable incidents inclusive of police and EMS on campus. Moving forward, all unusual incident reports will be submitted within 24 hours of occurrence. The new QA Manager has been trained on the collection and submission of incident reports and the requirements regarding DDAP, MCO's and the SCA submittals of incidents. The CEO will complete random audits that will ensure timely follow-up and submittals. |