INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 11, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Highland House, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
Based on a review conducted on May 10, 2016 of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following the occurrence of the unusual incident.
The incident dates are as followed:
12-5-15 Ambulance was present at the facility.
1-8-16 Ambulance was present at the facility.
1-21-16 Ambulance was present at the facility.
3-3-16 Ambulance was present at the facility.
|
Plan of Correction
Unusual incidents are currently completed by the staff on duty at the time of the incident when an ambulance, fire Department or other emergency agency is called to the halfway house.
The supervisor reviews the following day to assure that the paperwork has been sent to the proper authorities and then she scans the paperwork to the safety committee and the director for review. Hospital paper work is also attached to this report to be kept on file by the safety committee and the director. |