Observations
Based on a review of client records, 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 June 28, 2023, the facility was notified of the off-site death of a client. The facility had until July 3, 2023 to report the unusual incident to the Department; however, the incident was not reported to the Department as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will meet and conduct an in-service training with the facility directors regarding the unusual incident reporting policy to ensure that we are not only completing unusual incident reports when the presence of police and/or ambulance personnel is required but also sending them to the Department within three business days of the incident. To ensure this incident will not reoccur, all significant incidents reports must be securely emailed to the project director within 4 days of the incident with an attached written verification that the incident has been reported to DDAP within the three-business day timeframe. The verification will include day and time of report sent and name and signature of the individual who sent the report. All reports will be reviewed by the facility director prior to submission to DDAP and the Project Director.
The in-service training will be conducted no later than 12/29/23. |