Observations
The facility failed to document unusual incidents that required the presence of ambulance personnel.
The facility's unusual incident reports were requested on April 11, 2019. It was reported by facility staff that the ambulance had been present at the facility during the last licensing year; however, there was no documentation of these events.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director, along with the lead counselor, have created a file folder labeled "unusual incidents". All unusual incident forms that are submitted to DDAP will be stored in this file, which will be in a locked file cabinet.
The Lead Counselor will be responsible for filling out the unusual incident form.
The lead Counselor will be responsible for sending the completed unusual incident form to DDAP.
The Lead Counselor will be responsible for filing and keeping a copy of each form.
Furthermore, a digital copy of each unusual incident report will be preserved in the form of an email, since the forms will be emailed to DDAP. |