Initial Comments:
An initial validation survey visit was conducted on August 26 and 27, 2024. The purpose of this visit was to determine compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations for Medicare and Medicaid Participating Providers and Suppliers.
The ABH Pennsylvania Children's Services Inc. Goldsmith Left facility is in compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations for Medicare and Medicaid Participating Providers and Suppliers.
Plan of Correction:
Initial Comments:
An initial validation survey visit was conducted on August 26 and 27, 2024. 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 Children Under Age 21. The census at the time of the visit was seven, and the sample consisted of four 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 ordered by a physician or other licensed practitioner permitted by the State and the facility for one of two sample Resident who was restrained. This practice is specific to Resident #2 .
Findings include:
A review of the record for Resident #2, completed on 08/26/2024 between 9:30 AM and 11:00 AM, revealed that he was restrained on 11/21/2023. This restraint was noted on a document titled, "Restraint Progress Note". This report indicates that Resident #2 was restrained using a "Standing-2 arm control - 2 person" restraint at 3:49 PM, for a duration of 2 minutes,.and a "Supine-both arms up-4 person " restraint at 3:52, for a duration of
4 minutes. Further review of this ESI packet revealed that there was no evidence that a physician, or other licensed practitioner permitted by the State had ordered the use of the Standing-2 arm control restraint which was applied at 3:49 PM until 3:51 PM.
Interview with the Quality Improvement Coordinator on 08/27/2024, at approximately
09:45 AM, confirmed that the facility was unable to verify that a physician's orders was obtained for the use of the "Standing-2 arm control-2 person" restraint.
Plan of Correction:1. N/A - Physician's orders for emergency safety interventions for Individual #2 were not obtained following incidents of restraints.
2. 3 additional charts were reviewed on 8.26.24 and confirmed physician's orders present.
3. Upon the initiation of a restraint, a call will be placed by staff to the nursing department via walkie talkie or phone to alert the nurse of the restraint and requirement for physician's order. Refresher trainings occurred on 8.26.24 for Program Supervisors/Treatment Managers and Nursing department respectively to ensure notifications and documentation of physician's orders occur.
4. The nurse manager (or designee) will conduct a first level review within 24 hours of a restraint to ensure order has been obtained. Physician Orders will be sent to Program Supervisors/Treatment Managers to be placed in the individuals' charts. Quality Department will complete a monthly audit of ESI packets and provide written feedback to the Nursing Manager for follow up for any deficiencies identified during the audit process. Nursing Director will provide retraining to all physicians that do not meet the standard on a case-by-case basis as identified through the audit process that began on 8.15.24.
5. Oversight by Nursing Director. For any deficiencies identified during Quality Department's audit, Nursing Manager will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
483.358(f) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-
(1) The resident's physical and psychological status;
(2) The resident's behavior;
(3) The appropriateness of the intervention measures; and
(4) Any complications resulting from the intervention.
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within one hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions (ESI) and permitted by the state and the facility to assess the physical and psychological well-being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the Resident. This practice is specific to Resident #1.
Findings included:
A review of Resident #1's records was completed on 08/27/2024 from approximately 8:45 AM to 9:45 AM. This review revealed that this resident was restrained on 08/05/2024 at 7:40 PM until 7:45 PM. This restraint was documented on a form titled "Restraint Progress note". Further review of this packet revealed a form titled "Physician Order/Nursing Assessment. Under the section one hour face to face assessment of the physical and psychological well-being, it notes that Resident #1 was assessed by a nurse on 08/05/2024 at 9:55 PM, over the one hour time frame.
Interview with the Quality Improvement Coordinator on 08/27/2024 at approximately
9:45 AM confirmed that the face to face assessment of the physical and psychological well-being was not conducted within one hour post restraint.
Plan of Correction:1. N/A – Face to face assessments were not completed within one hour after the restraint for Individual #1.
2. 3 additional charts reviewed on 8.27.24 confirmed face to face assessments were completed within one hour of initiation of emergency safety intervention.
3. Upon the initiation of a restraint, a call will be placed to the nursing department via phone to alert the nurse of the restraint so an assessment can occur. When the nurse arrives to the unit for assessment, the nurse will verbally confirm the restraint(s) that were implemented and confirm the time they were initiated to ensure there is no miscommunication about the need for assessment and the assessment is completed in the correct allotment of time. Retraining of nurses of the expectation of one hour face to face assessments will be completed on 10.3.24.
4. The Nurse Manager (or designee) will conduct a first level review within 24 hours for each order of restraint to ensure a face-to-face assessment was completed by the nurse within one hour of initiation, and not during or prior to discontinuation, of an emergency safety intervention and will submit a copy of the nursing assessment to Program Supervisors/Treatment Managers to be placed in the individuals' charts. Quality Department will complete a monthly audit of ESI packets and provide written feedback to the Nursing Manager for follow up for any deficiencies identified during the audit process. Audit process began on 8.15.24.
5. Oversight by Nursing Director. For any deficiencies identified during Quality Department's audit process, Nursing Manager will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 (ESI) and the resident must have a face-to-face discussion. This discussion must include all staff involved in the intervention, except when the presence of a particular staff person may jeopardize the well-being of the resident. This practice is specific to Resident #2.
Findings include:
A review of the record of Resident #2 completed on 08/26/2024 between 9:30 AM and 11:00 AM revealed that he had been restrained on 11/21/2023 at 3:49 PM for a duration of 2 minutes and at 3:52 PM for a duration of 4 minutes. This incident of restraint was documented on an a form titled "Restraint Progress Note". A review of the client debriefing form which is included in this "Restraint Progress Note" packet, revealed that this client debriefing was conducted on 11/21/2023 at 4:05 PM and one of the five staff, identified as being involved in this ESI, was not present at this client debriefing. There was no indiction that their presence would jeopardize the wellbeing of this resident.
Interview with the Quality Improvement Coordinator on 08/26/2024 at approximately
10:40 AM confirmed that all staff involved, in the above mentioned restraint, were present at the client debriefing and there was no indication that this staff's present would jeopardize the wellbeing of this resident.
Plan of Correction:1. N/A – Client debriefing was not completed within 24 hours for resident #2.
2. Two additional records were reviewed on 9.20.24 and confirmed client debriefings were completed within 24 hours and all staff involved were debriefed regarding the restraint.
3. Supervisor and/or Safe and Positive Approaches trainers will meet with individual and all staff identified as involved in the physical intervention, within 24 hours for review of incident and identify strategies to prevent reoccurrence. Supervisor and/or Safe and Positive Approaches trainer will document reason staff involved was not present on the Individual/Staff Debriefing form as part of the restraint packet. For individuals who are non-verbal and unable to understand the process, Supervisor and/or Safe and Positive Approaches trainer will notify individual's assigned clinician of restraint for assistance in identifying strategies available and will document notification on the Individual/Staff Debriefing form. Retraining with Program Supervisor/Treatment Manager occurred on 9.20.24.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure client/staff debriefings have occurred and that all staff involved in the intervention are debriefed, or there is documentation present to support the rationale for staff absence. The Program Director, or designee, will provide supervisory follow up with staff not meeting this requirement, up to and including progressive disciplinary action. Quality Department will complete a monthly audit of ESI packets and provide written feedback to the Program Director for follow up for any deficiencies identified during the audit process. Audit process to begin 9.20.24.
5. Oversight by Program Administrator. For any deficiencies identified during Program Director's review, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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, staff involved in an emergency safety intervention (ESI) and appropriate supervisory and administrative staff, conducted a debriefing session that includes a review and discussion of the emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention. This practice is specific to Resident #2.
Findings include:
A review of the record of Resident #2 completed on 08/26/2024 between 9:30 AM and 11:00 AM revealed that he had been restrained on 11/21/2023 at 3:49 PM for a duration of 2 minutes and at 3:52 PM for a duration of 4 minutes. This incident of restraint was documented on an a form titled "Restraint Progress Note". A review of the staff/supervisor debriefing form which is included in this "Restraint Progress Note" packet, revealed that this staff/supervisor debriefing was conducted on 11/21/2023 at 4:10 PM and one of the five staff, identified as being involved in this ESI, was not present at this staff/supervisor debriefing. There is no indication as to why they were not in attendance.
Interview with the Quality Improvement Coordinator on 08/26/2024 at approximately
10:40 AM confirmed that the staff/supervision debriefing, did not include all staff involved in the emergency safety intervention and there was no indication as to why they were not in attendance.
Plan of Correction:1. N/A – Client debriefing was not completed within 24 hours for resident #2.
2. Two additional records were reviewed on 9.20.24 and confirmed client debriefings were completed within 24 hours and all staff involved were debriefed regarding the restraint.
3. Supervisor and/or Safe and Positive Approaches trainers will meet with individual and all staff identified as involved in the physical intervention, within 24 hours for review of incident and identify strategies to prevent reoccurrence. Supervisor and/or Safe and Positive Approaches trainer will document reason staff involved was not present on the Individual/Staff Debriefing form as part of the restraint packet. For individuals who are non-verbal and unable to understand the process, Supervisor and/or Safe and Positive Approaches trainer will notify individual's assigned clinician of restraint for assistance in identifying strategies available and will document notification on the Individual/Staff Debriefing form. Retraining with Program Supervisor/Treatment Manager occurred on 9.20.24.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure client/staff debriefings have occurred and that all staff involved in the intervention are debriefed, or there is documentation present to support the rationale for staff absence. The Program Director, or designee, will provide supervisory follow up with staff not meeting this requirement, up to and including progressive disciplinary action. Quality Department will complete a monthly audit of ESI packets and provide written feedback to the Program Director for follow up for any deficiencies identified during the audit process. Audit process to begin 9.20.24.
5. Oversight by Program Administrator. For any deficiencies identified during Program Director's review, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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