INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 20, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, Adappt House 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
Staff interviews were completed on July 20, 2017. Based on these interviews it was determined that the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident requiring presence of police, fire or ambulance personnel.
Facility staff members were interviewed and it was reported that the facility did not always submit an unusual incident report to DDAP when an ambulance was called to the facility to transport a client to the hospital.
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Plan of Correction
The Director or designee will notify 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.
All current staff have been trained to report to supervisory staff any incident that requires the presence of police, fire or ambulance personnel. The Director or designee will also complete an Unusual Incident Reporting Form-Non-NTP.
The Deputy Director will ensure that staff training sessions will be held periodically by supervisory staff to review the unusual incident procedure. Supervisory staff at these trainings will also re-enforce the need to immediately report any unusual incidents that occur at the facility.
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