Observations
Based on a review of internal incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving physical assault by staff or client.
A physical altercation between clients occurred on August 7, 2025, and on August 12, 2025. The facility did not submit an unusual incident report to the Department about these incidents.
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Plan of Correction
1. On August 21, 2025, the facility submitted unusual incident reports for the August 7 and August 12 incidents to DDAP.
2. Moving forward, all unusual incidents will be reported to DDAP within 72 hours of occurrence, in compliance with §709.34(c)(1).
3. The Compliance Director will personally submit all unusual incident reports directly to DDAP to ensure timeliness and consistency.
4. The Compliance Director will conduct quarterly reviews of incident reports to evaluate trends and ensure reporting compliance. Results will be shared at QA meetings with Facility Director/CEO and used for program improvements.
Responsible Party: Compliance Director. |