Observations
Based on a review of the facility's February 2024 through January 2025 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.
There were two events, documented in the logbook, which required police and/or ambulance personnel to be at the facility on September 20, 2024 and September 23, 2024; however, there was no documentation that either event was reported to the Department at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Additional language has been added to the CIU Manual clearly identifying name of form to be completed, time frame of 3 business days to complete, sign, and submit to DDAP, and email address to submit forms to once signed. Memo issued to all CIU staff and supervisors specific to unusual incidents and incident reporting form and time frame requirements. |