Observations
Based on a review of fire drill records, the facility failed to inform the Department of an unusual incident within the required three days.
It was discovered that the facility had an unusual incident occur on October 18, 2023 which involved an event at the facility requiring the presence of fire personnel. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In a review of our incident reporting protocols following the licensing findings, it was determined that staff did not follow procedure by submitting the required Unusual Incident Report. These are identified daily by Facility leadership to include Regional Director and OP Director and initiates the reporting to all applicable state and local entities.
Expectations regarding unusual incident reporting, as well as reportable criteria outlined in 709.34, were reviewed with all SUD staff during departmental meeting on 5/5/24. Clinical supervisors, nursing supervisors, and lead departmental assistants will review any new unusual incident reports with staff during weekly supervision to ensure an additional level of oversite regarding appropriate submission of these forms so that timely reporting may occur. |