Observations
Based on a review of client records, unusual incident reports, along with staff interviews, the facility failed to inform the Department of an unusual incident within the required three business days. It was discovered that ambulance personnel were on the premises on October 8, 2024. The facility did not submit a written unusual incident report to the Department within the regulatory timeframe.
|
Plan of Correction
In an effort to address citation 709.34 (c) (4), the following will be implemented:
Beginning 1/14/2025, the Program Director will ensure that the reporting of unusual incidents (709.34 (c)), including the presence of police, fire, or ambulance personnel is completed in the DDAP ERS within 3 days of the actual event.
The Director of Compliance will monitor the outcome of this action step when receiving daily internal incident reports. |