INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29-30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Treatment Trends, Inc. - Half-way Home of The Lehigh Valley Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
During a physical plant inspection of the facility completed on January 29, 2020, the facility failed to maintain to keep the grounds in good repair at all times for the safety and well-being of residents, employees, and visitors. On January 29, 2020, the facility's concrete steps leading from the gym area being used as a fire exit were in need of repair. The concrete steps were cracked and were chipping away as they were walked upon, this concern could cause potential hazards during fire drills or exiting.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation for § 705.2 Building exterior and grounds, new procedures will be implemented to assure the safety, sanitary, cleanness, and regular repair will be upheld for all clients and staff members alike while residing and working in the building. On January 29, 2020, the facility's concrete steps need to be repaired and failed to maintain to keep the grounds in good repair. The repairs to the steps will be fixed and completed ASAP, to prevent any potential hazards during fire drills or exiting the building. Effective immediately, the facility will be in full compliance with all standards for this policy. As a result of these actions, the following implementation have been put in place to correct these infractions:
- A routine schedule has been established and added to the monthly building checklist that will be overseen by the house manager and program director.
- The house manager will do a daily facility walk-through
- If any repairs are required, a maintenance request form will be completed and submitted
- The building maintenance department will execute all repairs when needed
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During the review of facility fire drill logs on January 29, 2020, the facility failed to maintain a written fire drill record including the time and problems encountered in six out of nine months of fire drills reviewed. On October 30, 2019 the facility failed to document the time the drill was completed.On April 20, 2019, May 23, 2019, June 26, 2019, October 30, 2019, November 27, 2019, and December 30, 2019 the facility failed to document if any problems had occurred as this was not completed on the fire drill log.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation for 705.10 (d) (4) Fire safety, new procedures will be implemented to oversee the written fire drill documentation which includes the indication of the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy.
The protocol will include:
- The clinical team/house manager and/or program director will conduct monthly fire drills held within the three shifts of operation
- The fire drill form will be completed after each fire drill, listing all detail information, number of clients and staff who participate in the drill, an indication of any problems that may occur, the exit doors used in the fire drill and the functionality of the smoke detectors
- Each fire drill will be completed and recorded and reviewed by the Quality Assurance officer
- Each section on the Fire Drill Form will be filled out, the parts that don't apply will be answered by writing N/A
- The program director will review and sign off on each fire drill once completed monthly
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a licensing inspection conducted on January 29-30, 2020, the project failed to provide documentation of the client being notified of their rights acknowledging that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven records reviewed. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To address the citation for § 709.30. Client rights, new procedures will be implemented to educate and ensure all clients understand their rights in the program. The client will sign a written acknowledgment of their rights, highlighting that the client was notified of those rights and that all information on the form was explained. Client Rights will be reviewed on the first day of admission, explaining that the resident's treatment experience may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The counselor and client will sign this documentation on the date of execution. A copy of the client's rights will be given to the resident at the end of the session. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
During a review of the project ' s medical policies and procedures on January 29-30, 2020, the project failed to include procedures for the use of vivitrol. The current procedures indicated all medication was self-administered. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To address the citation for § 709.32. Medication control, new procedures will be implemented to oversee the medical use of Vivitrol. The Medical Director, Program Director, and Medical Coordinator will enforce the procedures for Vivitrol. A licensed medical provider can only administer Vivitrol (RN, CRP, PA-C, DO, MD). All Vivitrol will be store in a double lock room that includes a locked refrigerator in the medical office within a locked office. All Vivitrol medication will be recorded on the date arrival, place the fridge, and will remain in the refrigerator until it is administered to the client. All Vivitrol medication and client information will be kept in the medication room in a double lock unit. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical or sexual assault by staff or a client. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34. Reporting of unusual incidents, new procedures will be implemented to discuss how to respond to the physical assault or sexual assault by staff or a client. Program Director revised employee training policy and client handbook to list the procedures individuals must follow if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy.
The protocol will include:
- Informing the Program Director and/or Executive Director of the assault through verbal or written communication
- The completion of an incident report
- Advocates may be involved in initial victim contact (via 24-hour hotline or face-to-face meetings); offer victims advocacy, support, and crisis intervention.
- Law enforcement representatives may be involved (e.g., 911 dispatchers, probation/parole officers, officers who process crime scene evidence, detectives, and investigators) that may respond to the initial complaints in the effort to enhance victim's safety.
- Health care providers may be involved to assess the individuals' care for acute medical needs and provide stabilization, treatment, and/or consultation.
- Information collected from the assault will be recorded and documented and fax/emailed to the DDAP office.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the selling or use of illicit drugs on the premises.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34. Reporting of unusual incidents, new procedures will be implemented to address the selling or use of illicit drugs on the premises. The Program Director reformed the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. When staff or client is made aware of or witness the selling or use of illicit drugs in the facility, the following protocol must be implemented:
- The Program Director, Clinical Supervisor and members of the clinical team will communicate with the residents and staff to secure safety within the facility
- The completion of an incident report documenting the events as they occurred
- A urine test will be requested, the urine sample collected and sent out for laboratory confirmation
- A build search will be conducted including the confiscation of any contraband found during the search
- If the selling of drugs occurs, staff will use universal precautions to collect any findings or evidence of drugs
- If an individual is engaging in illicit drug use, the individual will be asked to sit in the office where he/she can be monitored by staff
- An assessment will be conducted to get the individual into a higher level of care
- Law enforcement representatives may be involved (e.g., 911 dispatchers, probation/parole officers, officers who process crime scene evidence, detectives, and investigators) that may respond to the initial complaint if the situation requires it.
- If drugs are found in the facility, a clinical team member will gather the illicit substance and take it to the local police department
- The client and/or employee will be terminated from the program
- Employee Assistance Program (EAP) Services will be provided for all employees engaging in the use of illicit drugs
- A higher level of treatment care will be offered to the client who is participating in the use of illegal drugs based upon their assessment, funding provider and program acceptability
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (3) Reporting of unusual incidents, new procedures will be implemented to address unusual incidents involving death or severe injury due to trauma, suicide, medication error, or any particular circumstances. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy when staff is made aware of or involved in the death or severe injury due to trauma, suicide, medication error, or any particular circumstances, the following protocol must be implemented:
- Each unusual incident requires detail documentation. Every line on the incident form must be complete to the best of the staff member's ability
- All hospital, police, medical and mental health documentation must be attached to the unusual incident report within the compliance of HIPAA
- Corrective actions plans, suggestions and feedbacks will be added to each unusual incident report
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (4) Reporting of unusual incidents, new procedures will be implemented to address any significant disruption of services due to a disaster such as a fire, storm, flood or other occurrences that results in the closure of a facility for more than one day. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy the following protocol must be implemented:
- 911 will be called
- The facility will be evacuated to the assigned location; all corresponding documents will be taken out of the building (staff daily attendance sheet, client census, Emergency Preparedness Plan (EPP), client observation book)
- Staff will adhere to the emergency plan outline in the EPP manual
- Clients will be escorted to our neighboring sister program and will remain there until all it is safe to return to the facility
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving involving theft, burglary, break-in or similar incident at the facility. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (5) Reporting of unusual incidents, new procedures will be implemented to address any theft, burglary, break-in, or similar event at the facility. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol must be implemented:
- The Program Director and clinical team members will review all client and staff claims about any theft, burglary, break-in, or similar event at the facility
- Clients and employees will submit a verbal or written statement about the theft, burglary, break-in, or similar event at the facility
- 911 may be called if rendered
- An incident report will be completed
- The Program Director and Executive Director will review the incident report
- All legal documentation and photos will be attached to the incident report and submitted to the DDAP office
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of policies and procedures on January 29-30, 2020, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (6) Reporting of unusual incidents, new procedures will be implemented to address an event at the facility requiring the presence of police, fire, or ambulance personnel. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- The clinical staff member will obtain the names, professional titles of the emergency personnel, and first responders who arrive on the scene and documented on the incident form
- If medically required a copy of the client's medication log will be given to EMS or emergency medical personnel
- When an emergency occurs, staff will ensure the clients' safety around the building
- Employees will assist police, fire, or ambulance personnel when needed or directed
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to unusual incidents including fire or structural damage to the facility.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (7) Reporting of unusual incidents, new procedures will be implemented to address a Fire or structural damage to the facility. The policies and procedures on January 29-30, 2020 will be reviewed and amended to include the course of actions needed to manage the situation in case there is a fire or structural damage to the facility. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- When there is a Fire or structural damage to the facility, staff must call 911, secure the safety of the clients,
- Follow outline in the EPP plan,
- Document all events and obtain emergency personnel information and include it in the incident report.
- Complete a maintenance request form. The maintenance department will assess the damage and will make the needed repairs.
- The insurance company for the organization will be informed of the fire or structural damage.
- SCAs and other funders will be notified
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the outbreak of a contagious disease requiring CDC notification.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (a) (8) Reporting of unusual incidents, new procedures will be implemented to address an outbreak of a contagious disease requiring the Centers for Disease Control (CDC) notification. The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to manage an outbreak of a contagious disease requiring the Centers for Disease Control (CDC) notification. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- Reviewing all medical conditions and health needs with the client
- Informing Halfway Home's Medical Director of any contagious disease
- Sending the client to the local emergency room
- Contacting the department of health and adhering to their instructions as well as the Centers for Disease Control (CDC)
- Completing an incident report, listing all detail events and concerns
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures for the prompt review and identification of the causes directly or indirectly responsible for the unusual incident. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to handle the review and identification of the causes directly or indirectly responsible for the unusual incident. This policy and process will include the professional expertise of the Quality Assurance department and safety committee that will assist the Program Director in reviewing the directly or indirectly causes of the unusual incident. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- The program Director will review each unusual incident, provide comments and feedback and sign report
- The unusual incident report will be forwarded to the Quality Assurance department
- The Executive Director will review and sign off on the unusual incident report
- After Quality Assurance department reviewed the unusual incident report, it will be presented monthly in the safety committee for discussion.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures for the Implementation of a timely and appropriate corrective action plan, when indicated. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (b) (3) Reporting of unusual incidents, new procedures will be implemented to address the implementation of a timely and appropriate corrective action plan when indicated. The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to ensure the implementation of a timely and appropriate corrective action plan when indicated. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. All incident reports in this category will be submitted to the DDAP office. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- All incidents reports must be completed and given to the Program Director on the same date as it occurred.
- The time frame and corrective action plan will be given within 24 hours after the Program Director receives the report.
- The unusual incident report will be forwarded to the Quality Assurance department
- The Executive Director will review and sign off on the unusual incident report
- After the Quality Assurance department reviewed the unusual incident report, it will be presented monthly in the safety committee for discussion.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement policies and procedures for the ongoing monitoring of the corrective action plan. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (b) (4) Reporting of unusual incidents, new procedures will be implemented to address the ongoing monitoring of the corrective action plan. The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to ensure that a followup and monthly monitoring of the corrective action plans are being fulfilled and accomplished. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- All incidents reports will have a corrective action plan that will highlight the dates and time frames the infractions must be completed
- The corrective action plans will be followup by the Executive Director, Program Director, and/or House Manager ensuring that the managerial team is educating all parties involved and staying in compliance with the organization's policies and procedures
- Once the measure outlined in the corrective action plan has been completed, the Program Director will indicate the results on the report, closing the case.
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709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a review of policies and procedures on January 29-30, 2020, the project failed to develop and implement procedures in the project ' s incident report policy to include a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (b) (5) Reporting of unusual incidents, new procedures will be implemented to address the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to ensure that a reporting mechanism will be used to ensure the reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. All reports submitted will follow HIPPA regulations and State and Federal confidentiality laws. The facility will protect the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records except in limited circumstances. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- When writing an incident report, employees will adhere to the HIPPA, State and Federal confidentiality laws
- Employees will follow confidentiality guidelines governed by federal legislation (42 U.S.C. § 290dd-2) and regulations (42 CFR Part 2 and Substance Use Confidentiality laws) when revealing any information about the client
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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
During a review of the unusual incident reports for the year of 2019, on January 29-30, 2020, the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving 17 events at the facility requiring the presence of police, fire or ambulance personnel.The facility failed to report nine that required the presence of the police at the facility, two events that required the presence of fire personnel, and six events that required the presence of ambulance personnel at the facility. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To address citation § 709.34 (b) (6) Reporting of unusual incidents, new procedures will be implemented to address the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The policies and procedures on January 29-30, 2020, will be reviewed and amended to include the course of actions needed to ensure that the project shall file a written unusual incident report with the Department within three business days following an unusual incident involving, any event at the facility requiring the presence of police, fire or ambulance personnel. All unusual occurrences will be documented, recorded, and reviewed by the Program Director and Executive Director. The Program Director will renew the employee training policy and program procedures to include the following measures if and when these events may occur. Effective immediately, the facility will be in full compliance with all standards and procedures for this policy. The following protocol will be implemented:
- The incident report will be completed on the same day it occurred.
- The Program Director will review the report within 24 hours
- The unusual incident report will be forwarded to the Quality Assurance department
- The Executive Director will review and sign off on the unusual incident report
- When there is the presence of police, fire or ambulance personnel, the Program Director will complete DDAP incident report form and attached a copy of the facility's incident report and submit it within 72 hours by email or fax.
- The unusual incident report will be forwarded to the Quality Assurance department
- The Executive Director will review and sign off on the unusual incident report
- After the Quality Assurance department reviewed the unusual incident report, it will be presented monthly in the safety committee for discussion.
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