QA Investigation Results

Pennsylvania Department of Health
CARSON VALLEY SCHOOL - THISTLE COTTAGE
Health Inspection Results
CARSON VALLEY SCHOOL - THISTLE COTTAGE
Health Inspection Results For:


There are  5 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 March 1 and 2, 2017. 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 of under age 21. The census at the time of the survey was 12, and the sample consisted of six residents.













Plan of Correction:




483.356(d) ELEMENT
PROTECTION OF RESIDENTS

Name - Component - 00
Contact information. The facility's policy must provide contact information, including the phone number and mailing address, for the appropriate State Protection and Advocacy organization.



Observations:


Based on a review of the facility's restraint policies, and interview with administrative staff the facility failed to ensure that contact information of the state protection and advocacy organization, including phone number and mailing address was included in the facility restraint policy.

Findings included:

A review of the facility's behavior support and management plan policy dated January 2017, was completed on 03/02/2017 between 9:00 AM and 12:00 PM. This policy incorporates the use of personal restraint procedures as implemented at the facility.
Upon further review, it was noted that this policy does not include contact information , for the state protection and advocacy organization (Disabilities Right Network), including phone number and mailing address was included in this restraint policy.

Interview with director of social services and the compliance staff on 03/02/2017 at approximately 12:00 PM confirmed that the above policy does not include the contact information for Disabilities Rights Network.






















Plan of Correction:

Carson Valley Children's Aid added contact information including the phone number and mailing address for the State Protection and Advocacy Agency (The Disability Rights Network, The Philadelphia Building, 1315 Walnut Street, Suite 500, Philadelphia, PA 19107-4798; 215-238-8070) to the facility's Behavior Support and Management Policy #5 entitled Restraints Conditions for Use.


483.358(a) STANDARD
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.


Observations:

Based on record review and interview with administrative staff, the facility failed to ensure orders for restraint were ordered a physician or other licensed practitioner permitted by the State and the facility, and trained in the use of emergency safety interventions for two of four Residents who were restrained. This practice is specific to Resident #1 and #4.

Findings include:

1. A review of the records for Resident #1 and #4 was completed on 03/01/2017 from approximately 9:00 AM to 11:30 AM, and revealed the following information:

Resident #1:
A review of a critical incident report dated 09/13/2016 revealed that this Resident was restrained on 09/13/2016 from 8:45 PM until 9:00 PM. Attached to the critical incident packet was a restraint report dated 9/13/2016. Under the section of this report titled Restrictive Procedure order, there are spaces for the following to be documented; verbal order received by, licensed Practitioner issuing order, time limit to restraint and practitioners signature and date signed indicating that a physician ordered the restraint. On this report, all above mentioned spaces were blank. Further review indicated that
there was no other evidence that a physician or licensed practitioner ordered this restraint.

A review of a critical incident report dated 02/33/2017 revealed that this Resident was restrained on this date. Attached to the critical incident packet was a restraint report dated 2/23/2017. The section of this report titled Restrictive Procedure order there are spaces for the following to be documented; verbal order received by, licensed Practitioner issuing order, time limit to restraint and practitioners signature and date signed indicating that a physician ordered the restraint. On the space to document who received the verbal order, the entry " N/A " is written. The time limit to restraint space is documented with 1.5 minutes. All other mentioned spaces are blank. There is no other evidence that a physician or licensed practitioner ordered this restraint.

Resident #4 ;
A review of a critical incident report dated 07/29/2016 revealed that this Resident was restrained on this date. Attached to the critical incident packet was a restraint report dated 7/29/2016. Further review of this report revealed that page one of this report, which includes the physician's order for the use of restraint, is not incorporated within this critical incident report documentation. There is no evidence that the physician and or licensed practitioner ordered this restraint.

2. A review of the agency's policy titled Behavior Support and Management,
Policy BSM-7, revealed under the section titled, Orders for manual restraints the following;
-Orders for restraints must be obtained from the physician/psychiatrist or other licensed professional,
-An order for the restraint should be obtained prior to the intervention. If this is not possible due to the emergency nature of the situation, an order should be obtained during or immediately after the restraint has ended.

Interview with the Director of excellence on 03/02/2017 at approximately 9:45 AM, noted that this interviewee acknowledged that there were no physician's order in place for the above noted emergency safety interventions.





































Plan of Correction:

Core Elements 1 & 2

Orders for use of restraint or seclusion must be given prior to the initiation of a restraint or as possible following a restraint. Due to the lapse of time between this report and the restraints included in the statement of deficiency, Carson Valley Children's Aid is unable to correct the deficiencies for the specific individuals cited.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will include the timelines and required elements for orders. Staff will receive verbal and written instructions outlining the requirements that must be met to apply a restraint. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.

Core Element 4

Prior to the end of the shift in which the restraint took place, the cottage/education supervisor will review restraint reports to ensure all required elements are complete. The supervisor will prompt staff to add missing information and will coach staff on receiving and documenting orders for restraints.

Core Element 5

Carson Valley Children's Aid will monitor the presence and completeness of orders quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.358(d) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse, while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must verify the verbal order in a signed written form in the resident's record. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.



Observations:

Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that one of one verbal order for a restraint obtained during or immediately after the emergency situation ended, had been verified in a signed written form in the resident's record by the physician. for one of one sample individual who had a verbal order for a restraint. This practice is specific to Individual #3.

Findings include:

A review of the record of Individual #4 was completed on 03/01/2017 between
9:00 AM and 11:30 AM and revealed the following;

In a review of a document titled Significant Incident Report dated 10/27/2016 at
3:50 PM a second document titled Restraint Report, dated 10/27/2016 was attached. This restraint report contained a sub section titled Restrictive Procedure Order for a manual restraint or hold. This report indicates that the facility received a verbal order from the physician for a one minute restraint on 10/27/2016 at 4:00 PM. Beneath the entry for the duration of the restraint, is a line item on which the prescribing/practitioner's signature is listed. On this report, there is no signature by the Physcian who had authorized this restraint via verbal order to verify the verbal order given prior to the use of the restraint.

A review of the agency's policy titled Behavior Support and Management,
Policy #: BSM-7, page 31, revealed under the section titled, Orders for manual restraints:
-All orders for restraints must be signed by the ordering practitioner as soon as possible and placed in the child's record within 24 hours following the restraint.

Interview with the Director of excellence on 03/02/2017 at approximately 9:45 AM, acknowledged that the facility is aware that there are parts to the emergency safety intervention that were not documented, and that she was aware that there was no physician's order available for the above noted emergency safety intervention




















Plan of Correction:

Core Element 1

The physician who ordered the restraint will review and sign the verbal order form by 3/31/17.

Core Element 2

CVCA will review the records of all currently placed residents and will obtain missing signatures on verbal orders by 4/30/17.


Core Element 3
Effective 4/1/17, the Campus Compliance Specialist will review restraint packets for completeness within twenty-four hours of a restraint occurring. The Compliance Specialist will obtain missing signatures via in-person contact or electronic communication with the ordering physician/practitioner.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of orders quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.358(f) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-

(1) The resident's physical and psychological status;

(2) The resident's behavior;

(3) The appropriateness of the intervention measures; and

(4) Any complications resulting from the intervention.


Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within one hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions (ESI) and permitted by the state and the facility to assess the physical and psychological well-being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the Resident. This practice is specific to Residents #1.

Findings include:

1. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 09/13/2016 at 8:45 PM for a duration of 5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this packet revealed that the one hour medical assessment of the physical and psychological wellbeing of Resident #1 was not conducted until 09/14/2016 at 3:00 PM.

2. Interview with the Director of Excellence on 03/01/2017 at approximately 11:30 AM confirmed that the above mentioned one hour medical assessment was not conducted until the next day.


















Plan of Correction:

Core Elements 1 & 2

A face to face assessment of a resident's physical and psychological well-being must occur within one hour of an emergency safety intervention. Due to the lapse of time between this report and the restraints included in the statement of deficiency, Carson Valley Children's Aid is unable to correct the deficiency for the specific individual cited.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will include the timelines and required elements for post restraint assessments. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint packets quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding post restraint assessments is collected and corrective action plans are implemented if necessary.



483.358(g)(3) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
[Each order for restraint or seclusion must include] the emergency safety intervention ordered, including the length of time for which the physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion authorized its use.


Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that each order for restraint includes the emergency safety intervention ordered, including the length of time for which the physician authorized its use. This practice is specific to Resident #1, #3, #4,and #5.

Findings include:

A review of four sample Resident restraint records noted that orders for restraint did not include the emergency safety intervention ordered including the length of time for which the physician authorizes it use. Examples of this practice include the following:

Resident #1:
A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM, revealed that she had been restrained on 09/13/2016. This incident was documented on a critical incident report. Attached to this report is a document titled restraint report dated 09/13/2016. This restraint report has a section titled Restrictive Procedure Order. In this section of the restraint report there is a space provided to document the verbal order, who received said order,the name of the licensed practitioner issuing the order, time limit to restraint and the practitioner's signature and date. Continued review of this document revealed that neither the type or duration of the ordered restraint in listed or incorporated on this document.

Resident #4:
A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM, revealed that she had been restrained on 10/27/2016. This incident was documented on a critical incident report. Attached to this report is a document titled restraint report dated 10/27/2016. This restraint report has a section titled Restrictive Procedure Order. In this section of the restraint report there is a space provided to document the verbal order, who received said order,the name of the licensed practitioner issuing the order, time limit to restraint and the practitioner's signature and date. Continued review of this document revealed that neither the type or duration of the ordered restraint in listed or incorporated on this document.

A review of the agency policy titled Behavior Support and Management,
Policy #: BSM-7, page 30, revealed under the section titled, Orders for manual restraints;
-Orders for restraints must be obtained from the physician/psychiatrist or other licensed professional,
-An order [for the restraint] must specify ...the specific restraint ordered and the maximum duration of the personal restraint.

Interview with the Director of excellence on 03/02/2017 at approximately 9:45 AM, confirmed that the restraint report document described above lacked the requisite element of specific emergency safety intervention ordered, and that the time limit of restraint.



















Plan of Correction:

Core Elements 1 & 2

Orders for use of restraint or seclusion must be given prior to the initiation of a restraint or as possible following a restraint. Due to the lapse of time between this report and the restraints included in the statement of deficiency, Carson Valley Children's Aid is unable to correct the deficiencies for the specific individuals cited.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will include the timelines and required elements for orders. Staff will receive verbal and written instructions outlining the requirements that must be met to apply a restraint. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.

Effective 4/1/17, CVCA will implement a revised restraint report to highlight each required element in an order. The current restraint report requires staff to note the "Time Limit to Restraint" in the order section. This field will be changed to state "Duration".



Core Element 4

Prior to the end of the shift in which the restraint took place, the cottage/education supervisor will review restraint reports to ensure all required elements are complete. The supervisor will prompt staff to add missing information and will coach staff on receiving and documenting orders for restraints.

Core Element 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint reports quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.358(h)(2) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
[Documentation must include] the time the emergency safety intervention actually began and ended.



Observations:

Based on record review and interview with administrative staff, the facility failed to document the time emergency safety interventions actually ended for two of four sample Residents who were restrained. This practice is specific to Resident #1 and #4.

Findings include:

Resident #1:

A review of the record of Resident #1 completed on 03/01/2017 between 9 AM and
11:30 AM, revealed a document titled Restraint Report dated 02/23/2017. Under the section of Description of Restraint there is a space to record the time the restraint began and a space to record the time the restraint ended. Continued review of this document revealed that the start and end time of this restraint were left blank.

2. Resident #4:

A review of the record of Resident #4 completed on 03/01/2017 between 9 AM and
11:30 AM, revealed a document titled Restraint Report dated 07/29/2016. Further review of this restraint report revealed that the start and end time of this restraint was missing from this packet.

Interview with the Director of Excellence on 03/01/2017 at approximately 10:30 AM confirmed that the start and end times of the above mentioned restraints were not recorded.

















Plan of Correction:

Core Elements 1 & 2

Beginning and ending times of emergency safety interventions must be documented at the time a restraint is placed. Due to the lapse of time between this report and the restraints included in the statement of deficiency, Carson Valley Children's Aid is unable to correct the deficiencies for the specific individuals cited.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will emphasis the importance of noting beginning and ending times on required restraint reports. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.

Core Element 4

Prior to the end of the shift in which the restraint took place, the cottage/education supervisor will review restraint reports to ensure all required elements are complete. The supervisor will prompt staff to add missing information and will coach staff on monitoring and documenting beginning and ending times of restraints.

Core Element 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint reports quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.358(j) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION

Name - Component - 00
The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must sign the restraint or seclusion order in the resident's record as soon as possible.



Observations:


Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that the physician or other licensed practitioner permitted by the state and the facility to order restraint must sign the restraint order in the Resident's record as soon as possible. This practice is specific to Resident #4.

Findings include:

A review of the record of Resident #4's was completed on 03/01/2017 from approximately 9:00 AM to 11:30 AM. This review noted a document titled Significant Incident Report dated 10/27/2016 at 3:50 PM. This document states, "At the time, [Resident #4] was deemed a threat to herself and was placed in a physical restraint (not identified)." A review of an attached document titled Restraint Report, dated 10/27/2016 revealed a section titled Restrictive Procedure Order for a manual restraint or hold. The report indicates that the facility received a verbal order from the licensed practitioner on 10/27/2017 at 4:00 PM. However, the ordering practitioner failed to sign the restraint order in the resident's record.

A review of the agency policy titled Behavior Support and Management,
Policy #: BSM-7, page 31, revealed under the section titled, Orders for manual restraints revealed:
-All orders for restraints must be signed by the ordering practitioner as soon as possible and placed in the child's record within 24 hours following the restraint.

Interview with the Director of excellence on 03/02/2017 at approximately 9:45 AM, acknowledged that the facility is aware that there are parts to the emergency safety intervention that were not documented.


.























Plan of Correction:

Core Element 1

The physician who ordered the restraint will review and sign the verbal order form by 3/31/17.

Core Element 2

CVCA will review the records of all currently placed residents and will obtain missing signatures on verbal orders by 4/30/17.

Core Element 3

Effective 4/1/17, the Campus Compliance Specialist will review restraint packets for completeness within twenty-four hours of a restraint occurring. The Compliance Specialist will obtain missing signatures via in-person contact or electronic communication with the ordering physician/practitioner.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of orders quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.366(b) ELEMENT
NOTIFICATION OF PARENT(S) OR LEGAL GUARDIAN

Name - Component - 00
[If the resident is a minor as defined in this subpart] the facility must document in the resident's record that the parent(s) or legal guardian(s) has been notified of the emergency safety intervention, including the date and time of notification and the name of the staff person providing the notification.



Observations:


Based on record review and interview with administrative staff the facility failed to document in the resident's record that the parent(s) or legal guardian(s) has been notified of the emergency safety intervention, including the date and time of notification and the name of the staff person providing the notification for three at of four Residents that have been restrained. This practice is specific to Resident #1, #4, and #5

Findings include:

A review of three of four sample Resident restraint records noted that there is no documented evidence that the parent/legal guardian had been notified of a emergency safety intervention, including the time and date of notification and staff notifying the parent/legal guardian. Examples include the following:

1. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 09/13/2016 at 8:45 PM for a duration of 5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of the record for Resident #1 revealed that there is no documented evidence that Resident #1's parent/legal guardian was notified of this restraint.

2. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/27/2016 at 3:30 PM for a duration of 23 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of the record for Resident #4 revealed that there is no documented evidence that Resident #1's parent/legal guardian was notified of this restraint.

3. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 07/29/2016 at 4:00 PM (there is no indication on this Critical Incident Report, as to how long this resident was in restraint). This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of the record for Resident #4 revealed that there is no documented evidence that Resident #4's parent/legal guardian was notified of the restraint.

4. A review of the record of Resident #5 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/26/2016 at 2:55 PM for a duration of 12 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of the record for Resident #5 revealed that there is no documented evidence that Resident #5's parent/legal guardian was notified of the restraint.

5. Interview with the Director of Excellence on 03/01/2017 at approximately 11:30 AM confirmed that the facility's restraint packet were not complete and that the notification of parents/legal guardians were not consistently documented to verify that they were notified of the restraints.





































Plan of Correction:

Core Element 1

The assigned social worker will notify the parent/legal guardian of the restraint by 3/31/17. The Parent Notification will be documented in the case contact notes as well as on the Critical Incident Report associated with the restraint

Core Element 2

CVCA will review the records of all currently placed residents and will make all missing notifications by 3/31/17.

Core Element 3

Effective 4/1/17, the Campus Compliance Specialist will review restraint reports within twenty-four hours of a restraint occurring to ensure required notifications were made and documented. If an assigned social worker is unable to make the required notification, the Social Service Supervisor will notify the parent/legal guardian and document the contact on the Critical Incident Report and in the case notes.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint packets quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



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 Residents #1, #3, #4, and #5.

Findings include:

A review of four of four sample Resident restraint records noted that the resident debriefings inconsistently occurred within the 24 hours after the restraint, and that all staff involved in the restraint attended the debriefing, except when their presence may jeopardize the well-being of the resident. Examples of this practice include the following:

1. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 09/13/2016 at 8:45 PM for a duration of 5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. The section of the form titled Critical Incident Debriefing - Child indicates that there was one staff involved in the restraint. A review of this facility's resident debriefing form, notes that the debriefing for this restraint on 09/13/2017 at 8:45 PM does not indicate that the staff involved in this restraint was present at this debriefing. There was no further documentation as to why this staff was not in attendance.

2. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 02/23/2017 at 8:25 AM for a duration of 1.5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that a face-to-face discussion was held with Resident #1 within after this restraint.

3. A review of the record of Resident #3 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 11/23/2016 at 4:15 PM for a duration of less than 1 minute. This incident of restraint was documented on a form titled Critical Incident Report packet. The section of the form titled Critical Incident Debriefing - Child indicates that this debriefing occurred on 11/28/2016 at 1:00 PM, 5 days after the restraint. Continued review of this debriefing revealed that there is no indication that all staff involved in the restraint were present at this debriefing. There was no further documentation as to why this staff was not in attendance.

4. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/27/2016 at 3:30 PM for a duration of 23 minutes. This incident of restraint was documented on a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that a face-to-face discussion was held with Resident #4 after this restraint.

5. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 07/29/2016 at 4:00 PM (there is no indication on this Critical Incident Report, as to how long this resident was in restraint). This incident of restraint was documented on an a document titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that a face-to-face discussion was held with Resident #4 after this restraint.

6. A review of the record of Resident #5 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/26/2016 at 2:55 PM for a duration of 12 minutes. This incident of restraint was documented on an a document titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that a face-to-face discussion was held with Resident #5 after this restraint.

7. Interview with the Director of Excellence on 03/01/2017 at approximately 11:30 AM confirmed that the facility's restraint packet were not complete and that the client debriefings were inconsistently conducted. She indicated that the facility was aware of the issue of client debriefings not conducted after the restraint, within the 24 hour, and that all staff involved in the restraint must be present.











































Plan of Correction:

Core Elements 1 & 2

Post restraint debrief must take place within 24 hours of the restraint. Due to the lapse of time between this report and the restraints included in the statement of deficiency, it would not be clinically appropriate to facilitate the missed debriefs at this time.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will include a review of required post-restraint debriefings. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.
The Clinical Director is responsible for facilitating required debriefings. The Clinical Director will train on-call supervisors in debriefing protocols by 4/30/17. Effective 5/1/17, on-call supervisors will be responsible for facilitating required debriefings for restraints that take place on Friday evenings or Saturdays.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint debriefings quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



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 Residents #1, #3, #4, and #5.

Findings include:

A review of four of four sample Resident restraint records noted that the staff - supervisory debriefings inconsistently occurred within the 24 hours after the restraint and that all staff involved the restraint attended the debriefing. Examples of these include the following:

1. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 09/13/2016 at 8:45 PM for a duration of 5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that within 24 hours after the use of this restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, conducted a debriefing session.

2. A review of the record of Resident #1 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 02/23/2017 at 8:25 AM for a duration of 1.5 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that within 24 hours after the use of this restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, conducted a debriefing session.

3. A review of the record of Resident #3 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 11/23/2016 at 4:15 PM for a duration of less than 1 minute. This incident of restraint was documented on an a form titled Critical Incident Report packet. The section of the form titled Critical Incident Debriefing - Staff indicates that this debriefing occurred on 11/23/2016. Continued review of this debriefing revealed that two of the three staff involved in the restraint were present at this debriefing. There was no further documentation as to why the third staff was not in attendance.

4. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/27/2016 at 3:30 PM for a duration of 23 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that within 24 hours after the use of this restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, conducted a debriefing session.

5. A review of the record of Resident #4 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 07/29/2016 at 4:00 PM (there is no indication on this Critical Incident Report, as to how long this resident was in restraint). This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that within 24 hours after the use of this restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, conducted a debriefing session.

6. A review of the record of Resident #5 completed on 03/01/2017 between 9:00 AM and 11:30 AM revealed that she had been restrained on 10/26/2016 at 2:55 PM for a duration of 12 minutes. This incident of restraint was documented on an a form titled Critical Incident Report packet. Further review of this restraint packet revealed that there is no evidence that within 24 hours after the use of this restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, conducted a debriefing session.

7. Interview with the Director of Excellence on 03/01/2017 at approximately 11:30 AM confirmed that the facility's restraint packets were not complete,e and that the supervisory - staff debriefings were inconsistently conducted. She also noted that the facility was aware of the issue with client debriefings not conducted after the restraint, within the 24 hour, and that all staff involved in the restraint must be present.


































Plan of Correction:

Core Elements 1 & 2

Post restraint debrief must take place within 24 hours of the restraint. Due to the lapse of time between this report and the restraints included in the statement of deficiency, it would not be clinically appropriate to facilitate the missed debriefs at this time.

Core Element 3

The Director of Social Service/Campus Training Coordinator or her designee will retrain all staff in restraint protocols by 4/30/17. The training will include a review of required post-restraint debriefings. Visual reminders of CVCA's restraint protocols will also be posted in both residential and education buildings.
The Clinical Director is responsible for facilitating required debriefings. If a staff member who was present at the time of the restraint is unable to attend the debriefing in person, he/she will be provided the option of participating via conference call. The Clinical Director will train on-call supervisors in debriefing protocols by 4/30/17. Effective 5/1/17, on-call supervisors will be responsible for facilitating required debriefings for restraints that take place on Friday evenings or Saturdays.

Core Elements 4 & 5

Carson Valley Children's Aid will monitor the presence and completeness of restraint debriefings quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data regarding orders is collected and corrective action plans are implemented if necessary.



483.374(b) ELEMENT
FACILITY REPORTING

Name - Component - 00
Reporting of serious occurrences.
The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State designated Protection and Advocacy system.
Serious occurrences that must be reported include;
- a resident's death;
- a serious injury to a resident as defined in section 483.352 of this part; and
- a resident's suicide attempt.
(1) Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include
- the name of the resident involved in the serious occurrence,
- a description of the occurrence and,
- the name, street address, and telephone number of the facility.



Observations:


Based on review of resident records and interview with the administrative staff, the facility failed to report serious occurances of residents to the state designated protection and advocacy system for three of three sample Individuals reviewed who experienced serious occurrence as documented by the facility. This practice is specific to Resident #1, #3 and #4.

Findings include:

A review of the facility's incident reports and resident records completed on 03/02/2017 between 9:00 AM and 10:00 AM, revealed the following;

Resident #1;
On 08/24/2016, while the psychiatrist was visiting Resident #1's cottage, Resident #1 called the psychiatrist's name and asked her if she could "ask you something?" When the psychiatrist turned to look at Resident #1 she noticed a large bruise (larger or equivalent to the palm of a hand) visible on Resident #1's right arm. Resident #1 was unaware of how the injury occurred. The psychiatrist contacted the Childline to report possible abuse. Continued review of Resident #8's record did not reveal any evidence that the Pennsylvania protection and advocacy system (Disabilities Rights Network) had been notified of this serious occurrence.

Resident #3;
On 12/06/2016 at 2:00 PM, Resident #3 had been in a physical altercation with a peer in which she had been punched in the nose. After the altercation Resident #3 eloped from campus to her mother's home. Once Resident #3 was picked up her her mother's home, she was taken to the local hospital's emergency room. She was diagnosed with a mild left nasal fracture. Continued review of Resident #3's record did not reveal any evidence that the Pennsylvania protection and advocacy system (Disabilities Rights Network) had been notified of this serious occurrence.

Resident #4;
On 01/19/2017 at 4:15 PM, Resident #4 became anxious after witnessing a conflict between peers. She began to throw items and broke a window in the dining room with her right arm. She then took a piece of the broken glass with the intention of cutting herself. Staff intervened and took the glass from her. She was assessed by the on-campus nurse and was noted to have a deep laceration on her right inner wrist. She was sent to the local hospital's emergency room, via ambulance, for treatment. Continued review of Resident #8's record did not reveal any evidence that the Pennsylvania protection and advocacy system (Disabilities Rights Network) had been notified of this serious occurrence.

Interview with the Director of social services, and the campus compliance staff on 03/02/2017 at approximately 12:35 AM, revealed that the facility did not notify the Disabilities Rights Network of the above mentioned incidents of serious occurances.


















Plan of Correction:

Core Element 1

Carson Valley Children's Aid will submit notify the State Protection and Advocacy Agency of the serious occurrences by 3/31/17.

Core Element 2

CVCA will review the records of all currently placed residents and will make all missing notifications by 3/31/17.

Core Element 3

The Director of the Center for Excellence will review the deficiencies and CVCA's Critical Incident Reporting Procedure that outlines categories of injuries that are considered "serious occurrences" with the Administrative Assistant who is responsible for notifying the State Protection and Advocacy Agency of serious occurrences by 3/31/17. The Administrative Assistant will be provided with a copy of the definitions to refer to when processing Critical Incident Reports and making required notification.

Core Element 4

The Campus Compliance Specialist will review a sample of serious occurrence/Critical Incident Report notifications quarterly and provide feedback to the Administrative Assistant to ensure the deficient practice is being corrected and does not recur.

Core Elements 5

The Director for the Center of Excellence is responsible for ensuring the Campus Compliance Specialist completes required checks and corrective action plans are implemented if necessary.



483.374(b)(2) ELEMENT
FACILITY REPORTING

Name - Component - 00
In the case of a minor, the facility must notify the resident's parent(s) or legal guardian(s) as soon as possible, and in no case later than 24 hours after the serious occurrence.


Observations:


Based on review of the facility's documents and interview with administrative staff, the facility failed to notify the resident's parents or legal guardians as soon as possible, and in no case later than 24 hours after the serious occurrence for one of three sample residents with a serious occurrence. This practice is specific to Resident #1

Findings include:

A review of the facility's incident reports on 03/02/2017 between 9:00 AM and
10:00 AM revealed a incident report dated 08/24/2016. This incident report notes that while the psychiatrist was visiting Resident #1's cottage, Resident #1 called the psychiatrist's name and asked her if she could "ask you something?" When the psychiatrist turned to look at Resident #1 she noticed a large bruise (larger or equivalent to the palm of a hand) visible on Resident #1's right arm. Resident #1 was unaware of how the injury occurred. The psychiatrist contacted the Childline to report possible abuse. In further review, there was no evidence that Resident #1's parent/legal guardian was notified of this serious occurrence.

Interview with the Campus Compliance staff on 03/02/2017 at approximately 12:00 PM confirmed that Resident #1's parent was not notified.













Plan of Correction:

Core Element 1

The assigned social worker will notify the parent/legal guardian of the serious occurrence by 3/31/17. The Parent Notification will be documented in the case contact notes as well as on the Critical Incident Report associated with the restraint

Core Element 2

CVCA will review the records of all currently placed residents and will make all missing notifications by 3/31/17.

Core Element 3

The Social Service Supervisor is responsible for reviewing serious occurrence/Critical Incident Reports and required notifications within 24 hours of occurrence. If an assigned social worker is unable to make the required notification, the Social Service Supervisor will notify the parent/legal guardian and document the contact on the Critical Incident Report and in the case notes.

Core Elements 4 & 5

The Campus Compliance Specialist will review a sample of serious occurrence/Critical Incident Report notifications quarterly to determine whether or not required notifications are being made. Aggregate data regarding notifications will be reviewed quarterly in Performance and Quality Improvement meetings. The Campus Director is responsible for ensuring data is collected and corrective action plans are implemented if necessary.




483.376(f) ELEMENT
EDUCATION AND TRAINING

Name - Component - 00
Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis.


Observations:

Based on facility record review and staff training records, the facility failed to ensure that staff demonstrated their competencies in the use of emergency safety inventions on a semi annual basis.

Findings include:

A review of the facility documention regarding staff training for emergency safety interventions for the period of February 2016 through February 2017, was completed on on 03/02/2017 at approximately 10:00 AM. This review indicated that the residential nurse completed the training in the use of emergency safety interventions on 11/16/2016. There were no other dates indicating completion of any other trainings in emergency safety intervention training for this facility nurse.

Interview on 03/02/2017 at approximately 10:20 AM with human resources training staff noted that there was no further record that the above employee had completed further training or demonstration of the use of emergency safety interventions during the time period which was reviewed.
















Plan of Correction:

Core Element 1

The staff member's training is emergency safety interventions is current (11/16/16). The staff will be retrained in Safe and Positive Approaches prior to 5/16/16. CVCA is unable to correct the fact that staff did not complete the required training semi-annually prior to this date.

Core Element 2

The Director of Social Services/Campus Training Coordinator maintains a spreadsheet that identifies when staff is due to be retrained in emergency safety interventions. The spreadsheet will be reviewed by 3/31/17 and all Thistle staff who are out of compliance with the training requirement will be retrained by 4/15/17.

Core Elements 3, 4 and 5

Carson Valley Children's Aid has recent signed a contract with the Relias Learning Management system which includes electronic notification of training due dates. It is projected that the system will be fully implemented on campus by 7/1/17. In the interim, the Director of Social Service/Campus Training Coordinator will continue to track training using an excel spreadsheet and will notify staff and supervisors when training is due. Supervisors are responsible for ensuring staff attend assigned training sessions.