INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 15, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Spiritlife, Inc. 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
Based on a review of internal incident reports, the facility failed to inform the Department of an unusual incident within three business days. It was discovered that the facility had an unusual incident on August 5, 2022 which involved police being on site for which an unsual incident report was not submitted.
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Plan of Correction
Clinical Director updated policy and procedure to reflect that unusual incident reports must also be filed when police/probation show up with warrant for arrests for clients. Clinical Director has filed the incident report relating to the August 5th event. |