Initial Comments:
A validation survey was conducted February 5-7, 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. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted February 5-7, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Treatment Facilities. The census during the survey was nine and the sample consisted of six residents.
Plan of Correction:
483.360 STANDARD
CONSULTATION WITH TREATMENT TEAM PHYSICIAN
Name - Component - 00
If a physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion orders the use of restraint or seclusion, that person must contact the resident's treatment team physician, unless the ordering physician is in fact the resident's treatment team physician. The person ordering the use of restraint or seclusion must-
(a) Consult with the resident's treatment team physician as soon as possible and inform the team physician of the emergency safety situation that required the resident to be restrained or placed in seclusion; and
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that the physician that ordered a restraint contacted the individual's treatment team physician. This applied to two of 25 restraints reviewed. Findings included:
Record review for Individual #3 was completed on February 6, 2024. This review revealed that Individual #3 experienced restraints on January 19, 2024, and October 1, 2023. This review failed to reveal documentation that the ordering practitioner for these restraints contacted the treatment team physician for this individual to inform them of the restraints.
Interview with the director of residential services on February 7, 2024, at 9:08 AM, confirmed that there was no documentation that the ordering practitioner for the restraints that occurred on January 19, 2024, and October 1, 2023, contacted the treatment team physician to inform them of the restraints.
Plan of Correction:Program Directors/Treatment Coordinators/Program Managers ("Program Heads") will be retrained to thoroughly review clinical documentation, to include communication between physicians as part of restraint documentation. (This training will occur on or before 3/4/24 facilitated by Director of Residential Services). Existing deficiencies were corrected by notifying the treating physician.
During daily review of restraint documentation, Program heads will notify Director of Nursing if evidence of consultation between physicians is missing and Director of Nursing will notify the ordering physician to allow for consultation and documentation.
Representative from Health Information Management (HIM) will review submitted information for all restraints and ensure that applicable documentation of consultation between physicians is included. HIM representative will notify Director of Nursing if evidence of consultation between physicians is missing and Director of Nursing will notify the ordering physician to allow for consultation and documentation.
Adherence to this plan of correction will be reviewed in Performance Improvement Council on a quarterly basis.
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