Observations
Based on the client chart review and an interview with the facility director, the facility failed to submit an unusual incident report of police presence at the facility on September 13, 2021.
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Plan of Correction
As of 9/24/21, the Program Director will ensure that all Unusual Incidents will be submitted to DDAP within the regulatory timeframe. All incident reports will be reviewed by the Program Director, who will complete all external reporting. All incidents will be reviewed and discussed, including timely submission of reports, during weekly team meetings. All incidents will be recorded in a log book at the facility, which will be reviewed at least weekly by the Program Director. All program staff will complete our internal Incident Reporting training using the organization's online training system by 10/8/21. The Program Director/Clinical Supervisor will ensure that all staff training will be completed. Incidents will also be reported and discussed in the monthly Regional CQI Meetings. In addition, the Quality Assurance Department conducts quarterly program reviews, and the Compliance department conducts at least annual reviews of corrective action plans to ensure implementation. The unusual incident report specific to this event will be submitted 9/29/21 by the Program Director. |