Observations
Based on a complaint investigation conducted on September 1, 2022, the facility failed to file a written unusual incident report with the Department within 3 business days following an August 12, 2022 event that required the presence of police and/or ambulance personnel at the facility.These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The deficiency has been corrected. The facility has developed and implemented an updated policy and procedure according to the Licensing Alert 02-2018 "Reporting of Unusual Incidents", to include timely filing of an unusual incident report with the Department within 3 business days following the event that required the presence of police and/or ambulance personnel at the facility.
The updated policy shall be distributed to all staff. Ongoing monitoring of the corrective action plan will occur at the monthly Quality Assurance Committee meetings where the facility incident log is reviewed for compliance with policies and procedures.
In order to ensure that the deficiency does not recur, the project director will perform an annual review of all DDAP licensing alerts to ascertain the need to revise any policies and procedures to include any updates, accordingly.
The project director is responsible for updating and/or revising policies and procedures, per regulation 709.23, which states, "Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures." |