Failure to Notify Department of Health of Reportable Event
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event, as required by regulation 51.3 (g)(1-14). The deficiency was identified based on facility reports and staff interviews. On February 3rd, the fire alarm was activated, and the fire company arrived at the facility. During an interview, the Director of Nursing (DON) stated that they did not think it was necessary to report the incident. This oversight was confirmed by the DON, indicating a failure to comply with the notification requirements for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
Immediate Action: The fire alarm event was reported to the Department of Health and accepted. No substantial disruption of services occurred. All supervisors were instructed on reportable events and event reporting will be part of our yearly training sessions. Event reporting will be discussed at safety meetings and quarterly at QAPI meetings. Reportable incidents will be monitored by the Safety Officer and reported monthly at the Safety Committee. All reports will be submitted quarterly at QAPI. Staff in-services will instruct staff on notification of residents as to the status of the event (false alarm, partial evacuation, etc.). An event report was created for the Incident Commander or designee to complete the details of the event, what actions were taken, and who was notified of the event. Subsequently, the Department of Health will be notified according to PA Code 51.3. The Fire Policy was updated to include event reporting to the Department of Health. The corrective action will be completed by February 10, 2025.