INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1 - 3, 2019 by staff from the Department of Drug and Alcohol, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Cornell Abraxas 1, was found not to be in compliance with the applicable chapters of 28 Pa Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The policy and procedure manual was reviewed on April 2, 2019. The facility failed to include "selling or use of illicit drugs on the premises" in the unusual incident policy and procedure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 4, 2019, the Quality & Compliance Specialist revised the Reportable Incident Reporting policy to add "selling or use of illicit drugs on the premises" to the list of incidents requiring an unusual incident report.
The revised policy was reviewed with the Leadership Team during a meeting on April 9, 2019, and the revisions were approved. The revised policy will be reviewed with all employees during supervision meetings by May 31, 2019.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The policy and procedure manual was reviewed on April 2, 2019. The facility failed to include "Theft, burglary, break-in or similar incident at the facility" in the unusual incident policy and procedure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 4, 2019, the Quality & Compliance Specialist revised the Reportable Incident Reporting policy to add "Theft, burglary, break-in or similar incident at the facility" to the list of incidents requiring an unusual incident report.
The revised policy was reviewed with the Leadership Team during a meeting on April 9, 2019, and the revisions were approved. The revised policy will be reviewed with all employees during supervision meetings by May 31, 2019.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The policy and procedure manual was reviewed on April 2, 2019. The facility failed to include "ambulance personnel" in the unusual incident policy and procedure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 4, 2019, the Quality & Compliance Specialist revised the Reportable Incident Reporting policy to add "ambulance personnel" to the list of incidents requiring an unusual incident report.
The revised policy was reviewed with the Leadership Team during a meeting on April 9, 2019, and the revisions were approved. The revised policy will be reviewed with all employees during supervision meetings by May 31, 2019.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to submit a written unusual incident report with the Department for an incident regarding an ambulance being called to the facility. On 8-3-2018, an ambulance was at the facility and an incident report was not filed.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On April 4, 2019, the Quality & Compliance Specialist updated the address and fax number on the Department's Unusual Incident Report Form. The Quality & Compliance Specialist will be responsible for submitting incident reports that meet the Department's unusual incident reporting criteria, to include ambulance presence at the facility. The Quality & Compliance Specialist will maintain the reports in a binder with corresponding fax confirmation for each report.
This protocol was reviewed with the Leadership Team during a meeting on April 9, 2019 and was implemented April 10, 2019.
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