INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on July 18, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, ARS of Lancaster, LP 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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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of Unusual Incident Reports that were submitted to the Department since January 2022 and an interview with the facility director, the facility failed to inform the Department upon gaining knowledge of an unusual incident within the required 48 hours.
It was discovered that the facility was notified on July 8, 2022, that a patient passed away on January 3, 2022. The facility did not submit a written unusual incident report to Department within the regulatory 48 hours.
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Plan of Correction
Effective 07/19/2022 the Executive Director will ensure that unusual incident reports are completed within 48 hours of the notification of the incident. For the event in question for this report the incident report was submitted to correct the deficiency on 07/18/2022. This was for event number 835693. |