Observations
An on-site complaint investigatin was conducted by DDAP staff on April 13, 2017. Based on this review, the facility failed to file a written usual incident report with the Department within 3 business days following an unusual incident which involved the presence of police, fire or ambulance personnel. There was no documentation available to verify that this incident had been reported to DDAP.
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Plan of Correction
The Hillside Supervisory Team met on 4/18/17 to discuss the procedural breakdown that resulted in the failure to write and submit an unusual incident report regarding a detox waiting room client's overdose. The managers were provided with the DDAP guidelines as to the criteria of what incidents are to be reported to the bureau, and reviewed the facility policy that all internal and funder incident reports are to be completed by front line staff before the end of their shift. Those reports will be given to the department supervisors to forward to the facility director or, in his absence, the clinical supervisor to review and complete the DDAP Unusual Incident Report. To emphasize, either the Program Director or the Clinical Supervisor are responsible for the DDAP Unusual Incident Report. Department Supervisors are to educate their staff at their next monthly meetings to the DDAP unusual incident reporting requirements so they are aware when a supervisory home phone call is to be completed to expedite the DDAP reporting process. |