INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted January 5, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Lehigh County Center for Recovery 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 of administrative documents, the facility did not file a written unusual incident report with the Department as required.
An ambulance was at the facility on 8/24/2022 to transport a client to the emergency room. However, an unusual incident report was not filed with the Department.
This was discussed with facility staff during the complaint investigation.
|
Plan of Correction
This event occurred in between a staff position change. The person who was responsible no longer worked here and her responsibilities were transferred and missed. The Risk Manager has been identified as the is the backup person to enter this information and to review that all information is entered in a timely manner. |