Initial Comments:
A validation survey was conducted September 16-19, 2024, to determine compliance with the requirements of the 42 CFR Part 441, Subpart D Regulations for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was nine and the sample consisted of six residents.
Plan of Correction:
441.184(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on facility provided documentation and interview, it was determined that the facility failed to ensure that exercises were conducted to test the emergency plan twice per year. This applied to all the residents at the facility. Findings included:
Review of the facility provided documentation of the test of the emergency plan was completed September 17, 2024. This review revealed that the most recent test of the facility's emergency plan was conducted May 24, 2023.
Interview with the associate vice president of compliance (AVPC) completed on September 18, 2024, at 11:55 AM, confirmed that the facility's most recent test of the emergency plan was May 24, 2023, and that there was no documentation that the facility completed any test in the past year.
Plan of Correction:Sarah Reed agrees that two exercises to test the emergency plan did not occur twice within twelve months of the audit.
On 10/01/24, The Associate Vice President of Compliance will presented a revision of the Emergency Operations Plan that includes policy regarding the EP Testing Requirements in §441.184 to the Risk, Policy and Procedure Manual Committee (RPPM) for approval.
On 10/01/24, the AVP of Compliance presented present a revision of the Safety and Security Team bylaws to RPPM that charges the team with overseeing the implementation of two tests of the EOP each year, according to Federal Regulations.
The Safety and Security Team will submit the results of the testing to RPPM and include any recommended revisions to the Emergency Operations Plan.
The Associate Vice President of Compliance is responsible to monitor the implementation of this plan. The monitoring will occur by collecting the Safety and Security Teams testing the EOP for the next calendar year each January and then reviewing the EOP tests at all facilities, including those for the residential campus each quarter.
Initial Comments:
A validation survey was conducted September 16-19, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was nine and the sample consisted of six individuals.
Plan of Correction:
483.366 STANDARD
NOTIFICATION OF PARENT(S) OR LEGAL GUARDIAN
Name - Component - 00
If the resident is a minor as defined in this subpart:
483.366(a) The facility must notify the parent(s) or legal guardian(s) of the resident who has been restrained or placed in seclusion as soon as possible after the initiation of each emergency safety intervention.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that notification was made to the parent or guardian of the individual who had been restrained as soon as possible after the initiation of an emergency safety intervention (ESI). This applied to one (#4) of six individuals in the survey sample. Findings included:
Record review for Individual #4 was completed on September 17, 2024. This review revealed that Individual #4 experienced an ESI on July 31, 2024, at 7:52 PM. This review further revealed that the parent or guardian notification occurred on August 4, 2024, at 3:37 PM.
An interview was conducted with the senior director of residential services (SDRS) on September 18, 2024, at 11:45 AM. The SDRS confirmed that parent or guardian notification for Individual #4 was not completed as soon as possible following the initiation the ESI.
Plan of Correction:Sarah Reed agrees with the DOH's assessment that Individual #4 experienced an ESI on July 31, 2024 and that the parent or guardian was not contacted within 24 hours.
Residential leadership identified the cause of this deficiency as being training-related. Therefore, the Senior Director of Residential Services sent a program-wide email (Sent 9/25/2024) outlining the roles and responsibilities for completing the restraint form, including parent/guardian notification.
This information will additionally be added to the New Shift Leader training curriculum to be presented by the training support coordinator within the first two weeks of a new shift leader hire or promotion.
The Senior Director of Residential Services is responsible to maintain a system for daily communication between Unit Managers and Shift Leaders between shifts to ensure that restraint forms not finished by the end of the shift will be completed within 24 hours. The Record Auditor and Supervisor or Residential Nursing will continue audit the restraint forms weekly.
The Senior Director of Residential Services will review the weekly audit, determine the cause of any deficiencies, and take immediate action to resolve them.
The Sr. Director of Residential Services is responsible for the monitoring of this corrective action plan.
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 reviews and interview, it was determined that the facility failed to ensure that a face-to-face discussion was completed with the individual within 24 hours of the emergency safety intervention (ESI). This applied to one (#4) of six individuals in the survey sample. Findings included:
A record review was completed for Individual #4 on September 17, 2024. This review revealed that Individual #4 experienced an ESI on July 31, 2024, at 7:52 PM. This review further revealed that a face-to-face discussion occurred after the ESI on August 4, 2024, at 4:50 PM.
An interview was conducted with the senior director of residential services (SDRS) on September 18, 2024, at 11:45 AM. The SDRS confirmed that a face-to-face discussion did not occur within 24 hours of the above ESI for Individual #4.
Plan of Correction:Sarah Reed agrees with the auditors's assessment that Individual #4 that the face-to-face assessment occurred late.
The Hagan Unit Manager trained her team on restraint protocols during their staff meeting, the necessity of conducting a post intervention debriefing with the client within 24 hours of the intervention.
The Senior Director of Residential Services sent a program-wide email (Sent 9/25/2024) outlining the roles and responsibilities for completing the restraint form, including parent/guardian notification. This information additionally will be added to the New Shift Leader training curriculum to be presented by the training support coordinator within the first two weeks of a new shift leader hire or promotion.
On the same day, the Senior Director of Residential Services sent a program-wide email (Sent 9/25/2024) outlining the roles and responsibilities for completing the restraint form, including notifying the nurses of the restraint when the restrain has been initiated. This information additionally will be added to the New Shift Leader training curriculum to be presented by the training support coordinator within the first two weeks of a new shift leader hire or promotion.
The Manager of Employee Training and Staff Development will provide training on the I.E.S.C.A.P.E. model of client and staff debriefs during upcoming staff meetings.
The Senior Director of Residential Services is responsible to maintain a system for daily communication between Unit Managers and Shift Leaders between shifts to ensure that restraint forms not finished by the end of the shift will be completed within 24 hours. Record of this daily communication is recorded in a document on Sharepoint. Additionally, The Record Auditor and Supervisor of Residential Nursing will continue audit the restraint forms weekly and share the deficiency list with the Residential Managers and the Sr. Director of Residential Services.
The Senior Director of Residential Services will monitor this CAP by reviewing the nurses weekly audit as well as the Unit Manager's daily communication log on SharePoint.
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 reviews and interview, it was determined that the facility failed to ensure that all staff that participated in an emergency safety intervention (ESI) also participated in the post-intervention debriefing within 24 hours. This applied to one (#4) of six individuals in the survey sample. Findings included:
A record review was completed for Individual #4 on September 17, 2024. This review revealed that Individual #4 experienced an ESI on July 31, 2024, at 7:52 PM. This review revealed that the post-intervention debriefing occurred for this ESI on August 4, 2024, at 6:20 PM.
An interview was conducted with the senior director of residential services (SDRS) on September 18, 2024, at 11:45 AM. The SDRS confirmed that the above post-intervention staff debriefing did not occur within 24 hours of the ESI.
Plan of Correction:Sarah Reed agrees with the finding that the agency for individual #4, the post-intervention did not occur within 24-hours.
This deficiency was fixed through the post-intervention debrief occurring on August 4, 2024 at 6:20 PM.
The team leader of this restraint will be retrained regarding the need to include all parties in the staff debriefing.
The Senior Director of Residential Services is responsible to maintain a system for daily communication between Unit Managers and Shift Leaders between shifts to ensure that restraint forms not finished by the end of the shift will be completed within 24 hours. The Record Auditor and Supervisor of Residential Nursing will continue to audit the restraint forms weekly.
The Senior Director of Residential Services is responsible to maintain a system for daily communication between Unit Managers and Shift Leaders between shifts to ensure that restraint forms not finished by the end of the shift will be completed within 24 hours. Record of this daily communication is recorded in a document on Sharepoint. Additionally, The Record Auditor and Supervisor of Residential Nursing will continue audit the restraint forms weekly and share the deficiency list with the Residential Managers and the Sr. Director of Residential Services.
The Senior Director of Residential Services will monitor this corrective action plan by reviewing the nurses weekly audit as well as the Unit Manager's daily communication log on SharePoint.
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 provided training documentation and interview, it was determined that the facility failed to ensure that all staff demonstrated their competencies for safe crisis management (SCM) on a semiannual basis. This applied to two of 64 staff training records reviewed. Findings included:
Review of facility provided documentation of 64 staff training records for SCM was completed on September 18, 2024. This review revealed that one staff's most recent SCM training was dated December 10, 2023, and the second staff's most recent SCM training was dated December 23, 2023.
Interview with the supervisor of training and employee development on September 18, 2024, at 12:30 PM confirmed that these two staff, who were most recently trained in December 2023, were not trained in SCM on a semiannual basis.
Plan of Correction:Sarah Reed agrees with the auditors' findings that three staff members had not been trained in SCM on a semiannual basis.
The three staff members who were deficient in SCM training were given a one week deadline to complete their training or be suspended without pay. All three staff members completed their training.
The Manager of Employee Training and Development will provide the agency supervisors will list of due dates for their employees upcoming trainings at the first of the month. The supervisors will be expected to contact their reports and remind them of the training deadlines. Each month the director of the program will meet with the supervisors to ensure that these conversations regarding training deadlines are occurring.
The Manager of Training Staff Development is responsible to monitor this Corrective Action Plan. The monitoring will occur through the weekly review of reports on the agency's online learning platform.
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