Observations
Based on the client chart review and an interview with the facility director, the facility failed to submit an unusual incident report of police presence at the facility on March 19, 2021.
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Plan of Correction
ED, Performance Improvement Coordinator, and leadership team will review and train all parties, who facilitate the completion of incident reports, in accordance to Regulation 709.34C4 and that an unusual incident report needs to be submitted to DDAP within 3 business days of the event. The trainings will be documented in their supervision notes to be completed by all staff by 11/1/2021. It will be the Responsibility of the Supervisors and PIC to ensure the completion of incident reports by staff and to ensure staff will follow the current process for reporting to appropriate government agencies and providers. An unusual incident report was completed on 10/8/2021.
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