Observations
Based on a review of unusual incident reports and administrative documentation, the facility failed to report incidents involving physical assault by clients to DDAP within 3 business days.
Physical client altercations were documented on June 25 and June 26, 2025. There was no documentation of an unusual incident report being filed with DDAP for either of these incidents.
These findings were discussed with facility staff during the onsite complaint investigation.
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Plan of Correction
Effective immediately, the Clinical Supervisor, Facility Director, and/or Lead Counselor will submit all required incident reports within 24 hours of receiving facility documented incident reports from staff. The corporate compliance officer will review facility incident reports monthly to ensure consistency with reporting. |