QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOME OF YORK - GIRLS' CENTER
Health Inspection Results
CHILDREN'S HOME OF YORK - GIRLS' CENTER
Health Inspection Results For:


There are  6 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 November 14-16, 2016, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was 11 and the sample consisted of six individuals.








Plan of Correction:




441.151(a)(4) ELEMENT
BENEFICIARY AND ACCREDITATION REQUIREMENT

Name - Component - 00
Certified in writing to be necessary in the setting in which the services will be provided (or are being provided in emergency circumstances) in accordance with 441.152
(b) Inpatient psychiatric services furnished in a psychiatric residential treatment facility as defined in 483.352 of this chapter, must satisfy all requirements in subpart G of part 483 of this chapter governing the use of restraint and seclusion.



Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure a certificate of need was completed for all six individuals in the sample (Individuals #1, #2, #3, #4, #5, and #6) as required by 441.151 (a) (4), and 441.152. The findings included:

A) The records of Individuals #1, #2, #3, #4, #5, and #6 were reviewed on November 14-16, 2016. These reviews revealed that individuals were admitted to the facility as follows:

Individual #1 - November 1, 2016
Individual #2 - March 29, 2016
Individual #3 - February 9, 2016
Individual #4 - July 13, 2016
Individual #5 - September 27, 2016
Individual #6 - November 7, 2016

There was no documentation in the records that certified Individuals #1, #2, #3, #4, #5, and #6 needed inpatient psychiatric services provided in this psychiatric residential treatment facility (PRTF).

B) The program supervisor (PS) and licensed social worker (LSW) were interviewed on November 15, 2016, at 10:00 AM. The PS and LSW confirmed that there was no documentation in Individuals' #1, #2, #3, #4, #5, and #6 record of the certification of need for services provided by the PRTF.









Plan of Correction:

Certificate of Need has been developed and will be utilized for all admissions going forward. Current residents will also have a CON signed off at the next psychiatrist visit. The CON will be signed by both the psychiatrist and the RN.
Program Supervisor will be responsible to ensure that all recipients of service have a Certificate of need on file. Program supervisor will ensure all RN's are aware of the CON.
Vice President of Programs will ensure that this expectation is met via supervision. CQI Office will add this to their Quarterly File Review process. Results of the QFR are delivered to the program and VP of Programs at completion of the review for corrective action to take place. It is expected to have 100% compliance.
All charts are expected to be current by 1/31/2017.




441.154 ELEMENT
ACTIVE TREATMENT

Name - Component - 00
Active treatment.
Inpatient psychiatric services must involve "active treatment", which means implementation of a professionally developed and supervised individual plan of care, described in 441.155 that is-
(a) Developed and implemented no later than 14 days after admission; and
(b) Designed to achieve the beneficiary's discharge from in patient status at the earliest possible time.




Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure that a plan of care was developed and implemented by the entire interdisciplinary team within 14 days of the individual's admission to the facility as required by 441.154. This was noted for four individuals in the sample (Individuals #2, #3, #4 and #5). The findings included:

A) Individual #2's record was reviewed on November 14-16, 2016. The review revealed that Individual #2 was admitted to the facility on March 29, 2016, and the initial plan of care was developed on April 8, 2016. Further review revealed a signature page, dated April 8, 2016, for the initial plan of care, which did not include a signature from this individual's psychiatrist.

B) Individual #3's record was reviewed on November 14-16, 2016. The review revealed that Individual #3 was admitted to the facility on February 9, 2016, and the initial plan of care was developed on February 17, 2016. Further review revealed a signature page for the initial plan of care, signed and dated on March 8, 2016, by all team members.

C) Individual #4's record was reviewed on November 14-16, 2016. The review revealed that Individual #4 was admitted to the facility on July 13, 2016, and the initial plan of care was developed on July 18, 2016. Further review revealed a signature page for the initial plan of care meeting. The signature for this individual's psychiatrist was dated August 22, 2016.

D) Individual #5's record was reviewed on November 14-16, 2016. The review revealed that Individual #5 was admitted to the facility on September 27, 2016, and the initial plan of care was developed on September 29, 2016. Further review revealed that there was no signature page in the record that indicated the team members who participated in the initial plan of care meeting.

E) The licensed social worker (LSW) was interviewed on November 15, 2016, at 10:10 AM. The LSW confirmed that the entire interdisciplinary team did not review the initial plan of care developed for Individuals #2, #3, #4 and #5 within 14 days of admission to the facility.











Plan of Correction:

Initial Plans of Care are developed from the referral criteria and intake information gathered under the supervision of the psychiatrist within 14 days of admission. The psychiatrist, RN, youth and family will review all Plans of Care prior to delivery to the rest of the treatment team every 30 days after the initial Plan of Care. The psychiatrist and RN will sign the completed Plan of Care at the time of review with youth and family. Plans of Care are updated and reviewed every 30 days by the psychiatrist, RN, youth, family, and treatment team. The Therapist is responsible for coordinating the plan of care meetings with the psychiatrist, RN, youth and family. The program supervisor will ensure use a tracking system for due dates, and coordinate with the schedule of the psychiatrist to ensure plans of care are updated prior to the end of each 30 day period. VP of programs will review the schedule in supervision with the program supervisor. The Plan of Care and signature is on the CQI quarterly file review, and feedback from the review is provided to the Program Supervisor and the VP of Programs. All Plans of Care will be up to date by January 31, 2017. CQI/Compliance will conduct a focused audit in February for this measure.


441.156(c) ELEMENT
TEAM DEVELOPING INDIVIDUAL PLAN OF CARE

Name - Component - 00
The team must include, as a minimum, either-
(1) A Board-eligible or Board-certified psychiatrist;
(2) A clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; or
(3) A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases, and a psychologist who has a master's degree in clinical psychology or who has been certified by the State or by the State psychological association.



Observations:

Based on record review and staff interview, it was determined that the facility failed to ensure that the team, which developed and reviewed each individual's plan of care, included members as required by 441.156. This was noted for four individuals in the sample (Individuals #2, #3, #4, and #5). The findings included:

A) The record of Individual #2 was reviewed on November 14-16, 2016. The review revealed that Individual #2's initial plan of care was developed on April 8, 2016, and reviewed at least every 30 days by an interdisciplinary team. A signature sheet accompanied each review of the plan to indicate the team members' participation. The following plan of care meetings did not document the required team members' participation as outlined in the regulations:
- April 26, 2016 - psychiatrist signed May 6, 2016
- May 24, 2016 - psychiatrist signed May 31, 2016
- June 21, 2016 - psychiatrist signed June 27, 2016
- July 19, 2016 - psychiatrist signed August 8, 2016
- August 16, 2016 - psychiatrist signed September 12, 2016
- September 13, 2016 - psychiatrist signed October 4, 2016
- October 11, 2016 - psychiatrist signed October 20, 2016

B) The record of Individual #3 was reviewed on November 14-16, 2016. The review revealed that Individual #3's initial plan of care was developed on February 17, 2016, and reviewed at least every 30 days by an interdisciplinary team. A signature sheet accompanied each review of the plan to indicate the team members' participation. The following plan of care meetings did not document the required team members' participation as outlined in the regulations:
- May 3, 2016 - psychiatrist signed May 24, 2016
- June 28, 2016 - psychiatrist signed July 18, 2016
- July 26, 2016 - psychiatrist signed August 8, 2016
- August 23, 2016 - psychiatrist signed September 12, 2016
- October 18, 2016 - psychiatrist signed October 20, 2016

C) The record of Individual #4 was reviewed on November 14-16, 2016. The review revealed that Individual #4's initial plan of care was developed on April 8, 2016, and reviewed at least every 30 days by an interdisciplinary team. A signature sheet accompanied each review of the plan to indicate the team members' participation. The following plan of care meetings did not document the required team members' participation as outlined in the regulations:
- August 9, 2016 - psychiatrist signed August 22, 2016
- September 6, 2016 - psychiatrist signed October 20, 2016
- October 4, 2016 - psychiatrist signed October 20, 2016

D) The record of Individual #5 was reviewed on November 14-16, 2016. The review revealed that Individual #5's initial plan of care was developed on September 29, 2016, and reviewed at least every 30 days by an interdisciplinary team. A signature sheet accompanied each review of the plan to indicate the team members' participation. The following plan of care meetings did not document the required team members' participation as outlined in the regulations:
- October 25, 2016 - psychiatrist signed November 11, 2016

E) The program supervisor (PS) was interviewed on November 15, 2016, at 9:45 AM. The PS confirmed that the psychiatrist did not attend all of the review meetings and signed the signature sheets for Individuals #2, #3, #4, and #5 on a later date.








Plan of Correction:

Initial Plans of Care are developed from the referral criteria and intake information gathered under the supervision of the psychiatrist within 14 days of admission. The psychiatrist, RN, youth and family will review all Plans of Care prior to delivery to the rest of the treatment team every 30 days after the initial Plan of Care. The psychiatrist and RN will sign the completed Plan of Care at the time of review with youth and family. Plans of Care are updated and reviewed every 30 days by the psychiatrist, RN, youth, family, and treatment team. The Therapist is responsible for coordinating the plan of care meetings with the psychiatrist, RN, youth and family. The program supervisor will ensure use a tracking system for due dates, and coordinate with the schedule of the psychiatrist to ensure plans of care are updated prior to the end of each 30 day period. VP of programs will review the schedule in supervision with the program supervisor. The Plan of Care and signature is on the CQI quarterly file review, and feedback from the review is provided to the Program Supervisor and the VP of Programs. All Plans of Care will be up to date by January 31, 2017. CQI/Compliance will conduct a focused audit in February for this measure to ensure immediate compliance. Quarterly audits will continue to measure for this item for all new admissions for the 14 day adherence, and all youth in program for the ongoing plan of care.


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 documentation review and staff interview, it was determined that the facility failed to ensure that the physicians who ordered physical restraints were trained in the use of emergency safety interventions. This was noted for all four individuals who were physically restrained in the past year (Individuals #1, #2, #3, and #6). The findings included:

A) The record of Individual #3 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained on May 10, 2016, and July 5, 2016, as ordered by physician #1. Additionally, this individual was physically restrained on November 10, 2016, as ordered by physician #2.

B) The record of Individual #1 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained on November 3, 2016, as ordered by physician #1.

C) The record of Individual #2 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained on November 3, 2016, as ordered by physician #1.

D) The record of Individual #6 was reviewed on November 14-16, 2016. The review revealed that this individual was restrained on November 12, 2016, as ordered by physician #2.

E) The training records for physician #1 and physician #2 were reviewed on November 15, 2016. This review revealed no documentation that these two physicians were trained in the use of emergency safety interventions.

F) The facility's policy entitled Restrictive Procedures for Residential Services and Programs, revised February 24, 2012, was reviewed on November 14, 2016. This review revealed "manual physical restraint may only be used when ordered by a physician or other licensed practitioner permitted by the State and the facility to order restraint and trained in the use of emergency safety interventions".

G) The program supervisor (PS) was interviewed on November 15, 2016, at 2:50 PM. The PS confirmed that physicians #1 and #2 were not trained in the use of emergency safety interventions prior to ordering these techniques for Individuals #1, #2, #3, and #6.









Plan of Correction:

Two changes have been made by the program to the procedures for orders for physical interventions:
1.The Initial Restrictive Procedure Plan has been modified to identify allowable physical interventions for each client. The psychiatrist will sign off annually on the techniques which are delivered in accordance to the SCM training, and are approved for use at CHOY. This form will be in effect by January 1, 2017.
2. Also, a training has been developed that will educate the psychiatrist on the organizations use of physical interventions. CHOY uses SCM which offers least restrictive interventions, and de-escalation techniques. The psychiatrist will review this information by January 31, 2017. The Training Department will add Physical Intervention training to the list of necessary trainings that they are responsible for managing. Documentation will be kept in the physician personnel file.



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 record review and staff interview, it was determined that the facility failed to conduct a face-to-face discussion, which included all staff involved in the intervention and the individual, within 24 hours after the use of a restraint as required in 483.370. This was noted for two individuals in the sample who were physically restrained (Individuals #3 and #6). The findings included:

A) The record of Individual #3 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- May 10, 2016 - one time
- July 5, 2016 - two times
- November 10, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of each restraint, which included Individual #3 and all staff involved in the restraint.

B) The record of Individual #6 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- November 12, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of the restraint, which included Individual #6 and all staff involved in the restraint.

C) The facility's policy entitled Restrictive Procedures for Residential Services and Programs (revision February 24, 2012) was reviewed on November 14, 2016. This review revealed that within 24 hours after the use of the manual physical intervention, a debriefing must occur with the resident, the parent or legal guardian, and all staff involved in the intervention (except the inclusion of those staff whose inclusion might pose additional jeopardy to the well-being of the resident). Further review revealed topics of discussion to be included in this debriefing.

D) An interview with the director of compliance and quality (DoCQ), a licensed social worker (LSW) and program supervisor (PS), was conducted on November 16, 2016, at 10:30 AM. The DoCQ, LSW and PS confirmed that there was no documentation in the records of Individuals #3 and #6 that a debriefing was conducted with the individual after each use of a physical restraint.


















Plan of Correction:

It has been the expectation of the organization all along to engage in Post Physical Intervention Debriefings with the client and staff, and a separate debriefing with the staff only. The Program Supervisor will ensure that both debriefing occur and are documented, and submitted to CQI along with the Physical Intervention Incident Reports. Program Supervisor will review expectations, retrain as needed, and document in program staff meeting minutes.
The Program Supervisor and Vice President of Programs will review all Physical Intervention incidents, and supporting debriefing documentation at their weekly Individual Supervision Meetings.
CHOY CQI office will ensure that these debriefings are received with the Physical Intervention Incident reports, and immediate feedback is provided to program supervisor and VP of programs. Adherence to policy begins immediately.


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 record review and staff interview, it was determined that the facility failed to conduct a debriefing session, within 24 hours after the use of a restraint, that included all staff involved in the restraint and appropriate supervisory or administrative staff as required in 483.370 (b). This was noted for all four individuals in the sample who were physically restrained in the past year (Individuals #1, #2, #3 and #6). The findings included:

A) The record of Individual #3 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- May 10, 2016 - one time
- July 5, 2016 - two times
- November 10, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of each restraint, which included all staff involved in the restraint and a supervisory or administrative staff.

B) The record of Individual #6 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- November 12, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of the restraint, which included all staff involved in the restraint and a supervisory or administrative staff.

C) The record of Individual #1 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- November 3, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of the restraint, which included all staff involved in the restraint and a supervisory or administrative staff.

D) The record of Individual #2 was reviewed on November 14-16, 2016. The review revealed that this individual was physically restrained as follows:
- November 3, 2016 - one time

In addition, there was no documentation that a debriefing was conducted within 24 hours of the restraint, which included all staff involved in the restraint and a supervisory or administrative staff.

E) The facility's policy entitled Restrictive Procedures for Residential Services and Programs (revision February 24, 2012) was reviewed on November 14, 2016. This review revealed that within 24 hours after the use of the manual physical intervention, a debriefing which includes all staff involved in the intervention and appropriate supervisory/administrative staff must occur. Further review revealed the following topics of discussion to include in this debriefing:
- precipitating factors that led to the need for the intervention
- alternate techniques that may have prevented the need for the intervention
- procedures that staff are to implement to prevent any recurrence of the use of the intervention
- the outcome of the intervention, including any injuries.

In addition, staff must document the following in the resident's record:
- the names of the staff who attended this debriefing and those excused from the debriefing
- topics discussed and any changes to the treatment plan as a result from the debriefing.

F) An interview with the director of compliance and quality (DoCQ), a licensed social worker (LSW) and the program supervisor (PS), was conducted on November 16, 2016, at 10:30 AM. The DoCQ, LSW and PS confirmed that there was no documentation in the records of Individuals #1, #2, #3, and #6 that a debriefing was conducted with all staff involved in the restraint and a supervisor or administrative staff.

















Plan of Correction:

It has been the expectation of the organization all along to engage in Post Physical Intervention Debriefings with the client and staff, and a separate debriefing with the staff only. The Program Supervisor will ensure that both debriefing occur and are documented, and submitted to CQI along with the Physical Intervention Incident Reports. Program Supervisor will review expectations, retrain as needed, and document in program staff meeting minutes.
The Program Supervisor and Vice President of Programs will review all Physical Intervention incidents, and supporting debriefing documentation at their weekly Individual Supervision Meetings.
CHOY CQI office will ensure that these debriefings are received with the Physical Intervention Incident reports, and immediate feedback is provided to program supervisor and VP of programs. Adherence to policy begins immediately.


483.374(c) ELEMENT
FACILITY REPORTING

Name - Component - 00
Reporting of deaths. In addition to the reporting requirements contained in paragraph (b) of this section, facilities must report the death of any resident to the Centers for Medicare and Medicaid Services (CMS) regional office.

(1) Staff must report the death of any resident to the CMS regional office by no later than close of business the next business day after the resident's death.

(2) Staff must document in the resident's record that the death was reported to the CMS regional office.


Observations:

Based on documentation review and staff interview, it was determined that the facility failed to develop and implement policies and procedures consistent with the federal regulations. The findings included:

A) The facility's current policies and procedures for restraint and seclusion, as well as reportable incident requirements, were reviewed on November 14, 2016. The review revealed a policy entitled Reportable Incidents Requirements, revised December 10, 2013. This policy did not address the requirement for notification of the Centers for Medicare and Medicaid Services (CMS) of a child's death.

B) The program supervisor (PS) was interviewed on November 14, 2016, at 11:45 AM. The PS confirmed that the facility's policy for reportable incidents did not contain the requirement for the notification of the regional office of CMS in the case of a child's death.











Plan of Correction:

Director of Compliance provided the program with the forms [from the DOH website]required for notification of the Centers for Medicare and Medicaid Services (CMS) of a child's death. The required reporting information on whom to contact was also added to the existing CHOY policy on reportable incidents. The information was also added to the Incident Report Contact Form by the PRTF program for quick reference in use by the program. Program Supervisor will review expectation in staff meeting and document in staff meeting minutes.