Observations
Based on review of administrative paperwork, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
A review of the facility ' s unusual incident log indicated on July 8, 2025, there was the presence of police, fire or ambulance personnel; however, the report was not submitted to the Department until July 14, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with Pennsylvania Department of Drug and Alcohol Programs (DDAP) Licensing Regulation 709.34(c)(4) regarding the reporting of unusual incidents, all staff will complete retraining on the facility's Incident Management and Reporting Process no later than 5/26/2026. The training will include instruction on reportable incident definitions, required reporting timelines, and documentation expectations. A post-training competency assessment will be administered to confirm staff understanding. Documentation of training attendance and competency completion will be maintained and made available upon request.
The Director of Quality Management completed training on the Incident Management and Reporting Process on 5/1/2026 and is responsible for ongoing oversight of compliance with DDAP Regulation 709.34(c). Effective immediately, the Director of Quality Management will review incidents entered by facility staff in real time to ensure that all unusual incidents are identified, documented, and reported within required timeframes. Ongoing monitoring will be conducted to verify continued compliance with reporting requirements.
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