Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following a death or serious injury to due trauma, suicide, medication error or unusual circumstances.
On September 4, 2024, the facility was notified of the off-site death of a then-active client. At the time of the inspection, there was no documentation indicating the unusual incident was reported to the Department.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All client deaths will be reported to DDAP within 72 hours, by the OP Supervisor. OP Supervisor will remind all staff of DDAP's Unusual Incident policy and this will be reviewed at the next staff meeting on 2/21/25. |