Observations
Based on a review of client records, the facility failed to comply with the directive issued by the Department requiring the facility to implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents that include the requirement to report an unusual incident to the Department within 3 business days from the date of the unusual incident. As per a review of client records on 1/4/2016 - 1/5/2016 at the project's administrative office, client #6 died on 7/4/2015. The client was admitted to the facility on 6/16/2015. An unusual incident report was not submitted to the Department regarding the client's death as of 1/5/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Improvement reported the death of client #6 to the Department on 1/6/16. PCS has created a procedure to ensure that all unusual incidents indicated in Chapter 709 Subchapter C are reported to the Department within 3 business days. The Project Director and Facility Director will be responsible for ensuring ongoing compliance.
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