INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 18, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gateway Erie was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of incident reports between August 2022 and October 2022, the facility failed to file a written unusual incident report with the Department within 3 business days of an event at the facility that required the presence of ambulance personnel.
Unusual incidents occurred on 8/6/22, 8/17/22, 8/18/22 and 8/27/22 which involved ambulance personnel on site. The facility did not submit a written unusual incident report to the Department within the regulatory time frame.
This finding was reviewed with facility staff during the investigation.
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Plan of Correction
When an unusual incident occurs, the Clinical Supervisor will complete an Unusual Incident Report and submit it to the Facility Director to be reviewed. The Facility Director will submit the incident report to DDAP. This will occur within 3 business days of the unusual incident. On 04/21/2023 the Facility Director and Clinical Supervisor reviewed unusual incidents and the reporting procedures. |