QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOME OF READING YOUTH FAMILY
Health Inspection Results
CHILDREN'S HOME OF READING YOUTH FAMILY
Health Inspection Results For:

This is the only survey for this facility

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



Initial Comments:


An initial validation survey was conducted on August 30 through September 1, 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 for under age 21. The census at the time of the survey was 12, and the sample consisted of _6 residents.









Plan of Correction:




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 restraints were obtained from a physician or other licensed practitioner permitted by the State and the facility for two of six sample residents who required restraints. This practice is specific to Residents #1 and #2.

Findings include:

1. A review of the records for Residents # 1 and # 2 was completed on 08/31/2017 from approximately 8:45 AM to 12:30 PM. This review noted that these residents required the use of physical restraints that were implemented without a physician's order.

Resident #1:
A review of a document titled restrictive procedure report dated 07/22/2017, revealed that this resident was restrained by staff utilizing a standing assist, Hook Transport, on this same date from 9:06 PM until 9:07 PM. Further review of this document failed to reveal an order by a physician or other licensed personnel for the implementation of this restraint. Attached to this report was a hand written document titled, In lieu of Physical Restraint Assessment" dated 07/25/2017 that states, "Nurse on duty 7/22/17, 3-11 pm was not notified of hook transport of client, [Resident # 1]."

Resident #2:
A review of a document titled restrictive procedure report dated 08/11/2017 revealed that this resident was restrained utilizing a floor assist, supine torso and supine extension, on this same date from 2:35 PM until 3:07 PM. In further review, there was no order issued by a physician or other licensed personnel for the implementation of this restraint. Attached to this report was a hand written document titled, "In Lieu of Restraint Assessment" dated 08/24/2017 that states, "[A facility registered nurse] was the nurse on duty that day and was never made aware that this hold on Resident #2 happened so there is no...[physician's] order."

2. A review of the agency's policy titled, Passive Physical Restraint" dated 04/01/04 with the latest revision dated 5/14, revealed the following in the section titled Procedure:, point number 5.

-The nurse on duty or on-call is informed of a passive physical restraint as soon as possible and obtains an order from the physician or Licensed Independent Practitioner as soon as possible or within an hour.

Interview with the quality improvement specialist on 08/31/2017 at approximately 11:37 AM, confirmed there were no physician's order in place for the above noted restraints.














Plan of Correction:

1. How corrective actions will be accomplished for those individuals identified in deficiency statements: Starting immediately it will be the responsibility of the staff member initiating the restraint to communicate to the nurse on duty or on call that the restraint has occurred. It remains the responsibility of the nurse to contact the physician or Licensed Independent Practitioner (LIP) to receive the order for the restraint. The nurse documents the order on the form titled, Physician/Licensed Practitioner Restraint Order/Authorization. Those individuals identified in the deficiency statements will be required to attend a staff meeting on 10/10/17. During this meeting the importance of notifying the nurse on duty or the nurse on call about a restraint will be stressed and reviewed by The Residential Director, Program Manager, and/or The Shift Supervisor. Those in attendance will be required to verify their attendance on a sign in sheet, generated by The Program Manger or Shift Supervisor. The Residential Director will record the information discussed at the meeting on a meeting minutes note. She will then, within 24 hours of the meeting, e-mail the meeting minutes to all staff for their review. If the individuals identified in the deficiency statements, or any other staff, are not in attendance at this meeting The Program Manager and/or Shift Supervisor will meet with them within three days to review the importance of notifying the nurse of a restraint in order for the nurse to obtain the order from the physician or LIP.

2.How the facility will identify other individuals having the potential to be affected by the same deficient practice: Starting immediately it will be the responsibility of the staff member initiating the restraint to communicate to the nurse on duty or on call that the restraint has occurred. It remains the responsibility of the nurse to contact the physician or Licensed Independent Practitioner (LIP) to receive the order for the restraint. The nurse documents the order on the form titled, Physician/Licensed Practitioner Restraint Order/Authorization. All staff having the potential to be affected by this practice will be required to attend a staff meeting on 10/10/17. During this meeting the importance of notifying the nurse on duty or the nurse on call about a restraint will be stressed and reviewed by The Residential Director, Program Manager, and/or The Shift Supervisor. Those in attendance will be required to verify their attendance on a sign in sheet, generated by The Program Manger or Shift Supervisor. The Residential Director will record the information discussed at the meeting on a meeting minutes note. She will then, within 24 hours of the meeting, e-mail the meeting minutes to all staff for their review. If the individuals identified in the deficiency statements, or any other staff, are not in attendance at this meeting The Program Manager and/or Shift Supervisor will meet with them within three days to review the importance of notifying the nurse of a restraint in order for the nurse to obtain the order from the physician or LIP.

3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur: Starting immediately it will be the responsibility of the staff member initiating the restraint to communicate to the nurse on duty or on call that the restraint has occurred. It remains the responsibility of the nurse to contact the physician or Licensed Independent Practitioner (LIP) to receive the order for the restraint. The nurse documents the order on the form titled, Physician/Licensed Practitioner Restraint Order/Authorization. Also, upon the start of their shift all staff will test the radios provided to them by security personnel to be certain that they are charged and in proper working order. If the radio they are provided is not in proper working order they will request a working one. All staff having the potential to be affected by this practice will be required to attend a staff meeting on 10/10/17. During this meeting the importance of notifying the nurse on duty or the nurse on call about a restraint will be stressed and reviewed by The Residential Director, Program Manager, and/or The Shift Supervisor. Those in attendance will be required to verify their attendance on a sign in sheet, generated by The Program Manger or Shift Supervisor. The Residential Director will record the information discussed at the meeting on a meeting minutes note. She will then, within 24 hours of the meeting, e-mail the meeting minutes to all staff for their review. If the individuals identified in the deficiency statements, or any other staff, are not in attendance at this meeting The Program Manager and/or Shift Supervisor will meet with them within three days to review the importance of notifying the nurse of a restraint in order for the nurse to obtain the order from the physician or LIP.

4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: All Physician/Licensed Practitioner Restraint Order/Authorization forms will be reviewed by the Nurse Manger, Quality and Improvement Manager, and Quality Coordinator to assure that a restraint order was obtained and documented on the form. This will begin immediately. All Restrictive Procedure Reports will be reviewed by the Shift Supervisor, Program Manger, Quality and Improvement Manager, and Quality Coordinator to assure that the time of the restraint is accurately documented on this report. This will also begin immediately. The Security Manager will immediately begin to assure that radios are available and in working order for each staff member upon the start of their shift. She will be certain that other security personnel have radio not being used in a charger dock at all times. They will test the radio to be certain that it is working before giving it to a staff member.

5. Identify by position, who will be responsible for monitoring the corrective actions: The Nurse Manager, The Residential Director, The Program Manager, The Shift Supervisor, The Quality Manager and The Quality Coordinator, and Security Manager will be responsible for monitoring the corrective actions. Each of their expectations for doing so are outlined above.


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

Name - Component - 00
[Each order for restraint or seclusion must include] the date and time the order was obtained; and



Observations:

Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that each order for restraint include the date and time the order was obtained. This practice is specific to Residents #1 and #2.

Findings include:

1. A review of the record of Resident #1 revealed that this resident had been restrained on 07/23/2017 from 8:26 AM to 8: 44 AM. This restraint was documented on a report titled Restrictive Procedure Report and dated 07/23/2017. The verbal physician's order for this restraint was documented on a report titled Physician/Licensed Practioner Restraint Order/Authorization. In further review, there was no time or date documented as to when this order was received by the registered nurse.

2. A review of the record of Resident #2 revealed that this resident had been restrained on 07/23/2017 from 8:24 AM to 8: 27 AM. This restraint was documented on a report titled Restrictive Procedure Report dated 07/23/2017. The physician's order for this restraint was documented on a report titled Physician/Licensed Practioner Restraint Order/Authorization also dated 07/23/2017. Further review of this physician's order revealed there was no time documented regarding when this physician's order was received by the registered nurse.

3. A review of the agency's policy titled, "Passive Physical Restraint", effective date 04/01/04 with the latest revision dated 1/11 revealed the following in the section titled Procedure/ point number 7.
-Each order shall include...date and time order was obtained...for which the physician or Licensed Independent Practitioner authorized the passive physical restraint.

Interview with the quality improvement specialist on 08/31/2017 at approximately 10:00 AM confirmed that the above physician's order did not contain the time when the order was received.






















Plan of Correction:

1. How corrective actions will be accomplished for those identified in deficiency statements: The nurse on duty or on call is responsible for obtaining an order from the Physician or Licensed Independent Practitioner as soon as possible or within an hour and documenting it on the form titled Physician/Licensed Practitioner Restraint Order/Authorization. The Nurse Manager will be responsible for recording the accurate date and time of which the order is received. An error in documentation was made on the part of the individuals identified in the deficiency statement. In order to insure future errors do not occur The Nurse Manager will send an e-mail to the nurse's in her charge reminding them of the importance of accurately documenting the time and date of each restraint. She will also post a memo in the Nursing Station reminding the nurses of this need. The nurses will be expected to sign off on this memo, indicating that they have reviewed it. Both of these tasks will be completed by 10/13/17.

2. How the facility will identify other individuals having the potential to be affected by the same practice: All of the nurses on duty, or on call have the potential to be affected by this practice. In order to insure future errors do not occur The Nurse Manager will send an e-mail to the nurse's in her charge reminding them of the importance of accurately documenting the time and date of each restraint. She will also post a memo in the Nursing Station reminding the nurses of this need. The nurses will be expected to sign off on this memo, indicating that they have reviewed it. Both of these tasks will be completed by 10/13/17.

3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur: The Nurse Manager will review each completed Physician/Licensed Practitioner Restraint Order/Authorization to insure that the date and time which the restraint order was received from the physician or Licensed Independent Practitioner is documented. If the information is missing it will be returned for correction.

4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The Quality and Improvement Manager, and The Quality Coordinator will again review each completed Physician/Licensed Practitioner Restraint Order/Authorization to insure that the date and time which the restraint order was received from the physician or Licensed Independent Practitioner is documented. If the information is missing it will be returned for correction.

5. Identify, by position, who will be responsible for monitoring the corrective actions: The Nurse Manager, The Quality and Improvement Manager, and the Quality Coordinator will be responsible for monitoring this corrective action.


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 was evident for two of four sample residents who had been restrained, specifically
Residents #1 and #2.

Findings include:

1. A review of the records for Residents #1 and #2 was completed on 08/31/2017 from approximately 08:45 AM to 12:30 PM. This review noted that all staff who were involved in a restraint did not participate in the face to face discussion with the resident held 24 hours post the use of the restraint. The following is exemplary of this practice.

Resident #1:
A review of a restraint packet titled Restrictive Procedure Report dated 04/25/2017 revealed Resident #1 was restrained from 8:38 PM until 7:42 PM utilizing a standing assist upper torso and seated/kneeling assist upper torso. This section identified one staff person who implemented the restraint. Continued review of this packet revealed a document titled, Client Debriefing Summary. This debriefing occurred at 10:20 PM, the same day as the implementation of the restraint. However, the staff person who implemented the restraint was not present at this meeting, was not identified on the line provided on the form titled, "Excused", nor was there any information provided on the line that states, "If ALL staff were not involved in the client de briefing pleas document why."

2. A review of the agency's policy titled, "Debriefing Following a Restrictive Procedure". effective date 07/01/03 with the latest revision dated 10/1/09 revealed the following in the section titled Procedure: point number 1.

-Immediately following or within 24 hours of each restrictive procedure, all involved staff shall conduct an interview with the client, unless the presence of the involved staff jeopardizes the well being of the client. If all involved staff cannot participate, the reason for the absence should be documented on the client debriefing form.

Interview with the quality improvement specialist on 08/31/2017 at approximately 11:30 AM, confirmed not all staff who participated in the restraints attended the client debriefings and there was no documentation as to why the staff person failed to attend this debriefing.
















Plan of Correction:

1. How corrective actions will be accomplished for those individuals identified in deficiency statements: The individuals identified in the deficiency statements will be required to attend a staff meeting on 10/10/17 during which the debriefing expectations and proper documentation on the Client/Staff Debriefing form will be reviewed by the Residential Director, Program Manager and Shift Supervisor. This will be reflected as being addressed on the meeting minutes document which will be recorded by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. The Program Manager or Shift Supervisor will generate a sign in sheet to document attendance. If the individuals identified in the deficiency statements, or any other staff are not in attendance at the meeting on 10/10/17, the Program Manager or Shift Supervisor will meet individually, or as a group, with those not in attendance in order to review the debriefing expectations. The Program Manger and Shift Supervisor will be responsible for assuring attendance by completing a sign in sheet. This meeting will take place within three days of the staff meeting on 10/10/17. This review will be documented by the Program Manger or Shift Supervisor on a meeting minutes document. Notes taken at all staff meetings will be distributed via e-mail by the Program Manager or Shift Supervisor 24 hours following the meeting. This will assure that the information is received and available to all staff,present or absent. Also, all staff, including those identified in the deficiency statement, are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations, including documentation, as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. He will enter the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.

2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: It a necessary that all staff are aware of the debriefing expectations. Therefore, all staff will be required to attend a staff meeting on 10/10/17 during which the debriefing expectations and proper documentation on the Client/Staff Debriefing Form will be reviewed by the Residential Director, Program Manager and Shift Supervisor. This will be reflected as being addressed on the meeting minutes document which will be recorded by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. The Program Manager or Shift Supervisor will generate a sign in sheet to document attendance. If the individuals identified in the deficiency statements, or any other staff are not in attendance at the meeting on 10/10/17, the Program Manager or Shift Supervisor will meet individually, or as a group, with those not in attendance in order to review the debriefing expectations. The Program Manger and Shift Supervisor will be responsible for assuring attendance by completing a sign in sheet. This meeting will take place within three days of the staff meeting on 10/10/17. This review will be documented by the Program Manger or Shift Supervisor on a meeting minutes document. Notes taken at all staff meetings will be distributed via e-mail by the Program Manager or Shift Supervisor 24 hours following the meeting. This will assure that the information is received and available to all staff, present or absent. Also, all staff, including those identified in the deficiency statement, are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. The training Coordinator enters the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.


3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur: Staff meetings occur once per month, the next being 10/10/17. During these meetings the importance of completing and documenting the debriefing process will be stressed while being reviewed by the Residential Director, Program Manager and Shift Supervisor. All of the information presented at these meetings will be recorded on the meeting minutes document by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. This will assure that the information is received and available to all staff, present or absent. In addition, all staff are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations, including documentation,as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. The training Coordinator enters the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.


4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: Beginning immediately,attendance at all meetings will be recorded on a sign in sheet which is generated by the Program Manager or Shift Supervisor. All of the information discussed in the meetings will be disseminated to all staff via e-mail for their review. This will be completed by the Residential Director. The Training Coordinator is responsible for entering the attendance at Safe Crisis Management trainings into the computer data base that he has created. He will be responsible for communicating the names of individuals not in attendance to the Residential Director, Program Manager and/or Shift Supervisor. The Quality and Improvement Manager, along with the Quality Coordinator will review all Restrictive Procedures Reports (RPR) to ensure that the debriefings are taking place and being documented accordingly. If a RPR is found to be deficient it will be returned to the Program Manager or Shift Supervisor for correction.


5. Identify, by position, who will be responsible for monitoring the corrective actions: Those who have a responsibility for monitoring the corrective action are, The Residential Director, The Program Manager, The Shift Supervisor, The Training Coordinator, The Quality and Improvement Manager, and The Quality Coordinator. Their individual responsibilities are indicated above.
Direct Care Staff, Shift Supervisors, and/or QI Coordinator to ensure debriefings have been completed within the 24 hour time frame, include debriefings from each person involved in the restraint. If any staff involved in the restraint does not participate the reason for their absence is to be clearly stated on the client debriefing form. QI will review debriefings for the purpose of tracking possible patterns of staff absences. The Residential Program Manager, The Shift Supervisor, The Senior Direct Care Staff, The QI Manager, and The QI Coordinator will be responsible for monitoring this practice.


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 was evident for two of four sample residents who were restrained, specifically Residents #1 and #2.

Findings include:

Resident #1:
A review of a restraint packet titled restrictive procedure report dated 03/17/2017 revealed Resident #1 was restrained from 8:36 AM until 8:49 AM utilizing a standing assist hook transport and a floor assist supine torso. This section identified three staff persons who implemented the restraints. Continued review of this packet noted in the section titled, Staff Debriefing Summary, only two of three staff persons involved in the restraint attended the supervisory/staff debriefing, which included a discussion of the situation that required the emergency situation and the precipitating factors that led up to the restraint.

Further review of this document revealed that this section provides a space to document why any staff person involved in a restraint could not attend this debriefing.
There was no further information regarding the reason for the non-attendance at this meeting by the third staff person

Resident #2:
A review of a restraint packet titled restrictive procedure report dated 07/23/2017 revealed Resident #2 was restrained from 8:24 AM until 8:27 AM utilizing a seated/kneeling assist on the upper torso. This section identified three staff persons who implemented the restraint. Continued review of this packet noted in the section titled, Staff Debriefing Summary, revealed two of the three staff persons involved in the restraint attended the supervisory/staff debriefing, which included a discussion of the situation that required the emergency situation and the precipitating factors that led up to the restraint.

Further review of this document revealed that this section provides a space to document why any staff person involved in a restraint could not attend this debriefing.
There was no further information regarding the reason for the non-attendance at this meeting by the third staff person

2. A review of the agency's policy titled, "Debriefing Following a Restrictive Procedure". effective date 07/01/03 with the latest revision dated 10/1/09 revealed the following in the section titled Procedure, point number 3.

-Within 24 hours of the restrictive procedure, a debriefing with all staff involved in the restrictive procedure shall be conducted...If all staff involved cannot participate, the reasons for absence should be documented on the staff debriefing form.

3. Interview with the on 08/03/2017 at approximately 11:30 AM, confirmed not all staff who participated in the restraints attended the staff/supervisory debriefing nor could they provide documentation as to why the staff person did not attend.















Plan of Correction:

1. How corrective actions will be accomplished for those individuals identified in deficiency statements: The individuals identified in the deficiency statements will be required to attend a staff meeting on 10/10/17 during which the debriefing expectations will be reviewed by the Residential Director, Program Manager and Shift Supervisor. This will be reflected as being addressed on the meeting minutes document which will be recorded by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. The Program Manager or Shift Supervisor will generate a sign in sheet to document attendance. If the individuals identified in the deficiency statements, or any other staff are not in attendance at the meeting on 10/10/17, the Program Manager or Shift Supervisor will meet individually, or as a group, with those not in attendance in order to review the debriefing expectations. The Program Manger and Shift Supervisor will be responsible for assuring attendance by completing a sign in sheet. This meeting will take place within three days of the staff meeting on 10/10/17. This review will be documented by the Program Manger or Shift Supervisor on a meeting minutes document. Notes taken at all staff meetings will be distributed via e-mail by the Program Manager or Shift Supervisor 24 hours following the meeting. This will assure that the information is received and available to all staff,present or absent. Also, all staff, including those identified in the deficiency statement, are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. He will enter the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.

2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: It a necessary that all staff are aware of the debriefing expectations. Therefore, all staff will be required to attend a staff meeting on 10/10/17 during which the debriefing expectations will be reviewed by the Residential Director, Program Manager and Shift Supervisor. This will be reflected as being addressed on the meeting minutes document which will be recorded by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. The Program Manager or Shift Supervisor will generate a sign in sheet to document attendance. If the individuals identified in the deficiency statements, or any other staff are not in attendance at the meeting on 10/10/17, the Program Manager or Shift Supervisor will meet individually, or as a group, with those not in attendance in order to review the debriefing expectations. The Program Manger and Shift Supervisor will be responsible for assuring attendance by completing a sign in sheet. This meeting will take place within three days of the staff meeting on 10/10/17. This review will be documented by the Program Manger or Shift Supervisor on a meeting minutes document. Notes taken at all staff meetings will be distributed via e-mail by the Program Manager or Shift Supervisor 24 hours following the meeting. This will assure that the information is received and available to all staff, present or absent. Also, all staff, including those identified in the deficiency statement, are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. The training Coordinator enters the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.

3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur: Staff meeting occur once per month, the next being 10/10/17. During these meetings the importance of completing and documenting the debriefing process will be stressed while being reviewed by the Residential Director, Program Manager and Shift Supervisor. All of the information presented at these meetings will be recorded on the meeting minutes document by The Residential Director. The Residential Director will send out the meeting minutes via e-mail to all staff, those in attendance and those not in attendance, for all to review. This will be done within 24 hours of the meeting. This will assure that the information is received and available to all staff, present or absent. In addition, all staff are required to attend Safe Crisis Management Trainings (SCM) three times per calendar year. These trainings address debriefing expectations as part of the curriculum. The dates of the next SCM trainings are 10/24/17, 9/6/17, 9/21/17, 11/1/17, 11/16/17, 12/4/17, and 12/12/17. A sign in sheet is provided to document attendance. If a direct care staff is absent from the training they are required to attend the next available training. If they fail to do so they will be removed from the schedule until they complete the SCM training. The Training Coordinator is responsible for tracking attendance at SCM trainings. The training Coordinator enters the attendance in a computer data base that he has developed. The Program Manager and Shift Supervisor are responsible for reviewing attendance and assuring that staff attend the mandated SCM trainings.

4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: Beginning immediately,attendance at all meetings will be recorded on a sign in sheet which is generated by the Program Manager or Shift Supervisor. All of the information discussed in the meetings will be disseminated to all staff via e-mail for their review. This will be completed by the Residential Director. The Training Coordinator is responsible for entering the attendance at Safe Crisis Management trainings into the computer data base that he has created. He will be responsible for communicating the names of individuals not in attendance to the Residential Director, Program Manager and/or Shift Supervisor. The Quality and Improvement Manager, along with the Quality Coordinator will review all Restrictive Procedures Reports (RPR) to ensure that the debriefings are taking place and being documented accordingly. If a RPR is found to be deficient it will be returned to the Program Manager or Shift Supervisor for correction.

5. Identify, by position, who will be responsible for monitoring the corrective actions: Those who have a responsibility for monitoring the corrective action are, The Residential Director, The Program Manager, The Shift Supervisor, The Training Coordinator, The Quality and Improvement Manager, and The Quality Coordinator. Their individual responsibilities are indicated above.



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 one of one sample Individual reviewed who experienced a serious occurrence as documented by the facility. This practice is specific to
Resident #2.

Findings include:

A review of the facility's incident reports and resident records completed on 08/31/2017 between 9:00 AM and 12:00 AM, revealed the following;

Resident #2;
On 06/16/2017 at 7:00 PM, Resident #2 asked staff for a razor to shave her legs in the shower during her evening hygiene routine. At approximately 7:09 PM, Resident #2 exited the shower and showed staff a cut across her tongue and several cuts across her inner wrist and forearm. Staff immediately applied pressure to the cuts to stop the bleeding and contacted the nurse. At 8:10 PM, Resident #2 was transported to the local hospital's emergency department for treatment of left wrist lacerations, left forearm lacerations, and tongue lacerations. Continued review of Resident #2'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 vice president of clinical services and the quality improvement specialist on 08/31/2017 at approximately 09:30 AM, confirmed that the facility did not notify the Disabilities Rights Network of the above mentioned incident of serious occurances.




















Plan of Correction:

1. How corrective actions will be accomplished for those individuals identified in deficiency statements: On 9/2/17, The Disability Rights Network (DRN)was contacted by the Quality Coordinator in order to establish a process to communicate serious occurrences. The Quality and Improvement Manager and The Quality Coordinator will provide this information to DRN via fax or phone within 24 hours of the occurrence. This process began on 9/2/17.

2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: A policy will be developed by the Quality and Improvement Manager instructing others who may have the potential to be affected by the same deficient practice. The policy will provide instruction on who to inform of serious occurrences, their contact information, and instructions on how to complete this. This will be completed by 10/31/17.

3. What corrective measure or systematic changes will be put into place to insure that the deficient practice is being corrected and will not recur: A policy will be developed by the Quality and Improvement Manager instructing others who may have the potential to be affected by the same deficient practice. The policy will provide instruction on who to inform of serious occurrences, their contact information, and instructions on how to complete this. This will be completed by 10/31/17.

How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The Quality and Improvement Manager and The Quality Coordinator will be responsible for communicating the serious occurrences to the DNR and other pertinent individuals within the 24 hour time frame, either by fax or phone. The Q The Quality and Improvement Manager and The Quality Coordinator will develop a form to track the communication of serious occurrences. This will be completed by 10/31/17.

5.Identify, by position, who will be responsible for monitoring the corrective actions: The Quality and Improvement Manager and The Quality Coordinator will be responsible for monitoring actions.


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. This is specific to 13 of 17 staff persons working with the residents of this facility.

Findings include:

A review of the facility documention regarding staff training for emergency safety interventions for the period of August 2016 through August 2017, was completed on 09/01/2017 at approximately 9:30 AM. This review indicated that 13 residential staff completed only an annual training regarding the demonstration of the use of emergency safety interventions.

Interview on 08/31/2017 at approximately 10:20 AM with the vice president of clinical services confirmed that these staff had not completed a semi-annual demonstration training on the use of emergency safety interventions during the time period which was reviewed.






















Plan of Correction:

1. How corrective actions will be accomplished for those individuals identified in the deficiency statements: All of the individuals identified in the deficiency statements have since received the training or are no longer employed by The Children's Home of Reading. It is the intent of The Children's Home of Reading to ensure that all staff responsible for the use of emergency safety interventions receive refresher trainings in Safe Crisis Intervention (SCM)on a semi annual basis. Starting on 7/1/17 all staff are expected to complete two 8 hour physical refreshers once per year. In addition all staff are expected to complete a one 8 hour class emphasizing the verbal de-escalation techniques, behavior modification techniques, and relationship building as part of the SCM curriculum. Sign in sheets are generated by the Training Coordinator and all in attendance are required to sign. A data based tracking tool has been developed by and is being utilized by the Training Coordinator to track attendance in order to ensure that all employees receive all of their required trainings in a timely manner. If an employee fails to comply with the SCM training requirements put forth by the agency they will be removed from the schedule until they complete the requirements.

2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: All staff members have the potential to be affected by the same deficient practice. As such,starting on July 1 all staff are expected to complete two 8 hour physical refreshers once per year. In addition all staff are expected to complete a one 8 hour class emphasizing the verbal de-escalation techniques, behavior modification techniques, and relationship building as part of the Safe Crisis Management (SCM) curriculum. Sign in sheets are generated by the Training Coordinator and all in attendance are required to sign in. A data based tracking tool has been developed by and is being utilized by the Training Coordinator to track attendance in order to ensure that all employees receive all of their required trainings in a timely manner. If an employee fails to comply with the SCM training requirements put forth by the agency they will be removed from the schedule until they complete the requirements.

3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur: Starting on 7/1/17 all staff are expected to complete two 8 hour physical refreshers once per year, of Safe Crisis Management Training. In addition all staff are expected to complete a one 8 hour class emphasizing the verbal de-escalation techniques, behavior modification techniques, and relationship building as part of the Safe Crisis Management (SCM) curriculum. Sign in sheets are generated by the Training Coordinator and all in attendance are required to sign in. A data based tracking tool has been developed by and is being utilized by the Training Coordinator, as of 7/1/17, to track attendance in order to ensure that all employees receive all of their required trainings in a timely manner. If an employee fails to comply with the SCM training requirements put forth by the agency they will be removed from the schedule until they complete the requirements. The Quality and Improvement Department will receive quarterly reports from the Training Coordinator to review for all staff for the next year. Upon successful attainment of this measure, reports can be delivered in June and in December.

4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: Each staff member is assigned to one of four training teams which have specific dates for them to receive trainings. Upcoming trainings will be held on 10/24/17, 11/1/17, 11/16/17,12/4/17, and 12/12/17. Sign in sheets are generated by the Training Coordinator and all in attendance are required to sign in. A data based tracking tool has been developed by and is being utilized by the Training Coordinator, as of 7/1/17, to track attendance in order to ensure that all employees receive all of their required trainings in a timely manner. If a staff member fails to attend a training it is the responsibility of the Training Coordinator to inform the Program Manager of this. The Program Manager will then be responsible for speaking to the staff member and for adjusting the staff member's schedule in order for him to make up the training. If an employee fails to comply with the SCM training requirements put forth by the agency they will be removed from the schedule until they complete the requirements.

5. Identify, by position, who will be responsible for monitoring the corrective actions: The Residential Director, The Program Manager, The Training Coordinator, The Quality and Improvement Manager, and The Quality Coordinator will be responsible for monitoring this corrective action. Their individual roles are defined above.