QA Investigation Results

Pennsylvania Department of Health
FOUNDATIONS BEHAVIORAL HEALTH - DETERMINATION
Health Inspection Results
FOUNDATIONS BEHAVIORAL HEALTH - DETERMINATION
Health Inspection Results For:


There are  3 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


A validation survey was conducted on February 25 and 26, 2016. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart G regulations for Psychiatric residential treatment facilities for under age 21. The census at the time of the visit was 11, and the sample consisted of six Residents.







Plan of Correction:




483.370(a) STANDARD
POST INTERVENTION DEBRIEFINGS

Name - Component - 00
Within 24 hours after the use of the restraint or seclusion, staff involved in an emergency safety intervention and the resident must have a face-to-face discussion. This discussion must include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the wellbeing of the resident. Other staff and the resident's parent(s) or legal guardian(s) may participate in the discussion when it is deemed appropriate by the facility. The facility must conduct such discussion in a language that is understood by the resident and by the resident's parent(s) or legal guardian(s).
The discussion must provide both the resident and staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the resident, or others that could prevent the future use of restraint or seclusion.



Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, staff involved in an emergency safety intervention and the resident must have a face-to-face discussion. This discussion must include all staff involved in the intervention, except when the presence of a particular staff person may jeopardize the well-being of the resident. This practice is specific to
Resident #1.

Findings include:

A review of the record of Resident #1 revealed that he was restrained on the following dates: 06/03/2015, 06/28/2015, 07/08/2015, 07/25/2015, 09/05/2015, 09/06/2015, and 12/22/2015. In a review of the Restrictive Intervention order packets for all the above mentioned restraints, it was noted that there was no documented evidence that any of the staff involved in the above mentioned restraints attended the resident debriefings, or a stated reasons why staff did not attend the post debriefing.

Interview with the Quality Assurance Director on 02/26/2016 at approximately 9:15 AM confirmed that there was no evidence that the staff involved in the above mentioned restraints attended the post briefings with the resident. She stated that the signature sheets for the restraints mentioned above should have been with the Restrictive Intervention order packets and must have been misfiled.










Plan of Correction:

1. Foundations has provided staff re-education to all Nursing, Residential Treatment Facility (RTF), and Health Information Management (HIM) employees to ensure the corrected process is being adhered to. The Health Information Management Unit staff member has been properly trained in procedures and processes as it relates to the completion of the restraint packet.

2. Foundations has provided staff re-education to all Nursing, RTF, and HIM employees to ensure the corrected process is being adhered to.

3. Immediately following any restraints, staff participate in a debriefing session that includes staff involved, the resident, and administrative or supervisory staff member. Each individual signs a signature page indicating their participation in the debriefing session. Due to miscommunication in the medical records department with a new staff member, these completed signature pages were being removed from the packet and placed in standalone binders. This error has been identified and corrected as a result of this survey. All Nursing, HIM, and RTF were provided with staff education regarding the practice and process of completion of restraint paperwork. The signature pages are not to be removed by any individual. The debriefing will also occur immediately following the restraint. Packets will be reviewed within 24 hours by Nursing Administration to ensure the packet was completed correctly and in its entirety. The restraint packet will then be immediately filed in the appropriate section of the resident's chart.

4. Foundations Behavioral Health Nursing Leadership will inspect each restrictive intervention for completeness and accuracy. Nursing will ensure that all parties involved in the restrictive intervention have signed the signature page indicating they participated in the debriefing session. Additionally, Nursing Leadership will audit approximately 30% of the restraint packets on a monthly basis (separate from the initial inspection) and after they have been filed in the residents chart to ensure the packet is correctly filed and all pages are present, and all elements are completed. The results of the audits will be reported to the FBH Performance Improvement (PI) Committee on a quarterly basis.

5. The Chief Nursing Officer, the Director of Nursing, and the RTF Nurse Manager will be responsible for ensuring the corrective measures are implemented and faulty practices do not occur. These individuals will also be responsible for auditing each restraint packets as well as conducting the monthly audits and reporting 30% to the PI Committee on a quarterly basis.



483.370(b) ELEMENT
POST INTERVENTION DEBRIEFINGS

Name - Component - 00
Within 24 hours after the use of restraint or seclusion, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session that includes, at a minimum, a review and discussion of -

483.370(b)(1) The emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention;




Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session to discuss the precipitating factors that lead up to the intervention. This practice is specific to Resident #1.

Findings include:

A review of the record of Resident #1 revealed that he was restrained on the following dates: 06/03/2015, 06/28/2015, 07/08/2015, 07/25/2015, 09/05/2015, 09/06/2015, and 12/22/2015. In a review of the Restrictive Intervention order packets for all the above mentioned restraints, it was noted that there was no documented evidence that any of the staff involved in the above mentioned restraints, and appropriate supervisory and administrative staff participated in the debriefing sessions for the listed restraints.

Interview with the Quality Assurance Director on 02/26/2016 at approximately 9:15 AM confirmed that there was no evidence that the staff involved in the above mentioned restraints attended the debriefings with supervisory or administrative staff. She stated that the signature sheets for the restraints mentioned above should have been with the Restrictive Intervention order packets and must have been misfiled.







Plan of Correction:

1. Foundations has provided staff re-education to all Nursing, Residential Treatment Facility (RTF), and Health Information Management (HIM) employees to ensure the corrected process is being adhered to. The Health Information Management Unit staff member has been properly trained in procedures and processes as it relates to the completion of the restraint packet.

2. Foundations has provided staff re-education to all Nursing, RTF, and HIM employees to ensure the corrected process is being adhered to.

3. Immediately following any restraints, staff participate in a debriefing session that includes staff involved, the resident, and administrative or supervisory staff member. Each individual signs a signature page indicating their participation in the debriefing session. Due to miscommunication in the medical records department with a new staff member, these completed signature pages were being removed from the packet and placed in standalone binders. This error has been identified and corrected as a result of this survey. All Nursing, HIM, and RTF were provided with staff education regarding the practice and process of completion of restraint paperwork. The signature pages are not to be removed by any individual. The debriefing will also occur immediately following the restraint. Packets will be reviewed within 24 hours by Nursing Administration to ensure the packet was completed correctly and in its entirety. The restraint packet will then be immediately filed in the appropriate section of the resident's chart.

4. Foundations Behavioral Health Nursing Leadership will inspect each restrictive intervention for completeness and accuracy. Nursing will ensure that all parties involved in the restrictive intervention have signed the signature page indicating they participated in the debriefing session. Additionally, Nursing Leadership will audit approximately 30% of the restraint packets on a monthly basis (separate from the initial inspection) and after they have been filed in the residents chart to ensure the packet is correctly filed and all pages are present, and all elements are completed. The results of the audits will be reported to the FBH Performance Improvement (PI) Committee on a quarterly basis.

5. The Chief Nursing Officer, the Director of Nursing, and the RTF Nurse Manager will be responsible for ensuring the corrective measures are implemented and faulty practices do not occur. These individuals will also be responsible for auditing each restraint packets as well as conducting the monthly audits and reporting 30% to the PI Committee on a quarterly basis.