Observations
Based on a review of unusual incident reports, along with staff interviews, the facility failed to inform the Department of an unusual incident within the required three business days. It was discovered that police were on the premises on October 20, 2024. The facility did not submit a written unusual incident report to the Department within the regulatory timeframe.
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Plan of Correction
The incident on October 20, 2024, will be submitted by January 28, 2025, through the portal. Foster Hill Wellness will ensure that all reportable incidents are submitted through the online portal within three business days. A training covering all reportable incidents will take place on or before January 28, 2025. This training will be completed during the hiring process and will occur annually for all employees thereafter.
Additionally, we will review all incidents during our weekly leadership meetings to ensure proper reporting. The Chief Operating Officer (COO) will be responsible for maintaining ongoing compliance. |