Initial Comments:
A validation survey was conducted June 10-13, 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 73 and the sample consisted of 10 residents. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted June 10-13, 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 73 and the survey sample consisted of 10 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, it was determined that the facility failed to ensure that an order by a physician or other licensed practitioner was obtained at the time of an emergency safety intervention (ESI). This applied to one (#3) of 10 individuals in the survey sample. Findings included:
A record review for Individual #3 was completed on June 12, 2024. This review revealed that Individual #3 experienced an ESI on March 22, 2024, at 7:20 PM. The documentation for this ESI included a note from the registered nurse (RN) that stated that they had not been notified of the restraint on the day it occurred. This review further revealed an order for this restraint dated March 27, 2024.
An interview with the administrator of quality services (AQS) and administrator of program compliance (APC) was completed on June 13, 2024 at 1:25 PM. At this time, the AQS and APC both confirmed that for the above ESI experienced by Individual #3 on June 12, 2024, the RN was not notified at the time it occurred and did not obtain an order until five days after the restraint had occurred.
Plan of Correction:The documentation identified in the deficiency statement does not need corrected as an order was ultimately obtained but not in the required time frame. Of the 3 individuals involved in the restrictive procedure, only 1 individual remains employed at The Bradley Center. On July 2, 2024, this individual received re-education regarding securing an order through our Nursing Department at the time of the restrictive procedure.
The Therapeutic Crisis Intervention quarterly refresher for our training year's quarter 4 (July – September 2024) will include notification of the Nursing Department as soon as safely possible upon the initiation of the restrictive procedure. The Director of Residential Services and Senior Clinical Manager are responsible for developing the curriculum and the Training Department and Therapeutic Crisis Intervention Trainers will be responsible for implementing the training.
In the month of July 2024, The Bradley Center Restrictive Procedure Order and Report Form will be revised to include a prompting box indicating that the Nursing Department was notified at the time of the restrictive procedure to protect other individuals that could be affected by the same deficient practice. Leadership will be responsible for confirming that the Nursing Department was notified at the time of the Restrictive Procedure.
The corrective action will be monitored by having all Restrictive Procedure Order and Report Forms reviewed by the Clinical Manager and Nurse Manager to ensure complete, accurate and timely documentation and notification. The Clinical Manager and Nurse Manager will report their findings to the Director of Residential Services.
The Director of Residential Services will be responsible for monitoring the corrective action plans.
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 record reviews, interviews, and facility provided telehealth assessment practice, it was determined that the facility failed to ensure that face-to-face comprehensive physical assessments occurred within one hour of emergency safety interventions (ESI). This applied to two (#6 and #8) of 10 Individuals in the survey sample. Findings included:
1. (a) A record review for Individual #6 was completed on June 12, 2024. This review revealed a report of an ESI, which occurred on January 7, 2024, from 10:46 PM until 12:13 AM. The medical assessment for this ESI report included a note by the registered nurse (RN) that stated it had been completed via telehealth.
A review of the facility provided telehealth assessment practice was completed on June 13, 2024. This review revealed that the facility practice is as follows, "In the absence of an onsite registered nurse, the assessment may be completed via a HIPPA compliant online conferencing platform."
1. (b) The record review for Individual #6 further revealed three occurrences in which the post-ESI physical assessment was initially refused by Individual #6 but not reattempted by the RN. This occurred on the following:
-A supine restraint on April 18, 2024, at 3:03 PM
-A supine restraint on March 19, 2024, at 7:36 PM
-A supine restraint on February 21, 2024, at 6:32 PM
2. A record review was completed for Individual #8 on June 12, 2024. This review revealed that Individual #8 was involved in an ESI on April 23, 2024. Further review revealed that the RN attempted one post-ESI physical assessment that was refused by Individual #8 on April 23, 2024. This review failed to reveal documentation that a post-ESI physical assessment was completed for Individual #8.
An interview with the administrator of quality service (AQS) and administrator of program compliance (APC) was completed on June 13, 2024, at 1:28 PM. At this time the AQS and APC both confirmed that for the ESI for Individual #6 on January 7, 2024, a comprehensive face-to-face assessment did not occur. The AQS and APC further confirmed that it was their practice to have telehealth as an option for post-ESI assessments. The AQS and APC further confirmed that there was no documented post-ESI assessment for Individual #8 and that further attempts at assessment should have been completed.
Plan of Correction:N483.358(f)
Upon review of the Restrictive Procedure Order and Report Forms, it was determined that the same Registered Nurse did not document additional attempts to conduct the physical assessment on the 4 identified restrictive procedures. On June 27, 2024, The Nurse Manager met with the identified nurse to discuss the requirement and responsibility to document all attempts to conduct a physical assessment on a resident post restrictive procedure. The documents identified in the deficiency statement are unable to be corrected as too much time has passed to accurately complete a physical assessment.
As of June 12, 2024, The Bradley Center no longer allows a physical health assessment following a restrictive procedure to be conducted via telehealth. All physical health assessments following a restrictive procedure will be conducted face-to-face. If there is not a Registered Nurse on site, one will be assigned to be on call and will report to the agency to conduct a physical assessment after all Restrictive Procedures to protect other individuals that could be affected by the same deficient practice.
By July 15, 2024, post restraint assessment and documentation training will be provided to the registered nurses through both in person discussion with the Nurse Manager and Relias, the online training platform. In the future, any newly hired registered nurses will receive this training during orientation to protect other individuals that could be affected by the same deficient practice.
In the month of July 2024, the Restrictive Procedure Order and Report form will be revised by the Administrator of Program Compliance to include a prompter that if the resident refuses the initial physical assessment, observations of the resident's appearance will be documented and that additional attempts should be made and documented.
The Director of Nursing will review all Restrictive Procedure Order and Report Form orders to verify that the assessment was completed including any additional attempts. The Director of Nursing will report her findings to the Chief Program Officer.
Chief Program Officer will be responsible for ongoing monitoring the corrective action plan.
483.358(g)(3) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Each order for restraint or seclusion must include] the emergency safety intervention ordered, including the length of time for which the physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion authorized its use.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all orders for emergency safety interventions (ESI) included the specific length of time for which the intervention is permitted by the ordering physician. This applied to one (#10) of 10 individuals in the survey sample. Findings included:
Record review for Individual #10 was completed on June 12, 2024. This review revealed that on April 16, 2024, Individual #10 experienced a supine restraint which lasted 12 minutes. Further review failed to reveal documentation of the length of time that was ordered by the physician for the ESI implemented.
An interview was conducted with the administrator of program compliance (APC) and administrator of quality services (AQS) on June 12, 2024, at 11:52 AM. The APC and AQS confirmed that there was no documented time from the ordering physician for the ESI implemented on April 16, 2024, for Individual #10.
Plan of Correction:The Restrictive Procedure Order and Report Form was updated with the length of time that was prescribed by the Psychiatrist to correct the deficiency.
Any resident that requires a restrictive procedure has the potential to be affected by the deficiency.
Post restraint assessment and documentation training including documenting all components of the Psychiatrist Order will be provided to the registered nurses through both in person discussion with the Nurse Manager and Relias, the online training platform. In the future, any newly hired registered nurses will receive this training during orientation.
The Nurse Manager will review all Restrictive Procedure Order and Report Form orders to verify that all components of the order were documented on the form. Random audits will also be completed by the Nurse Manager monthly.
The Director of Professional Development and Training will ensure that the in-person discussion is conducted, and that the information is posted to RELIAS as well.
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 reviews and interviews, it was determined that the facility failed to ensure that a notification was made to the parent or guardian of the resident who has been restrained as soon as possible after the initiation of an emergency safety intervention (ESI). This applied to two (#1 and #3) of 10 individuals in the survey sample. Findings included:
1. A record review for Individual #1 was completed on June 12, 2024. This review revealed that Individual #1 experienced two successive ESI's on February 23, 2024, at 3:59 PM and then at 4:00 PM. Further review revealed that parent or guardian notification occurred on March 7, 2024, at 8:58 AM.
2. A record review for Individual #3 was completed on June 12, 2024. This review revealed that Individual #3 experienced an ESI on March 22, 2024, at 7:20 PM. This review further revealed that the parent or guardian notification occurred on March 24, 2024, at 4:00 PM.
An interview was conducted with the administrator of program compliance (APC) and administrator of quality services (AQS) on June 13, 2024, at 12:28 PM. The APC and AQS confirmed that parent or guardian notification for Individuals #1 and #3 were not completed as soon as possible following the initiation of an ESI.
Plan of Correction:Two individuals were identified as being the responsible parties for the notification to the residents' parents/guardians as soon as possible that a restrictive procedure occurred. Only one of these individuals is still employed by The Bradley Center. On July 2, 2024, this individual was reminded about the process and timeframe for family notification. The documentation as identified in the deficiency statement does not need to be corrected as notification was ultimately made but not in the required time frame.
The Therapeutic Crisis Intervention quarterly refresher for our training year's quarter 4 (July – September 2024) will include notification to the family of the restrictive procedure. The Director of Residential Services and Senior Clinical Manager are responsible for developing the curriculum and the Training Department and Therapeutic Crisis Intervention Trainers will be responsible for implementing the training. It is the responsibility of unit leadership for the shift to make parent notifications for restrictive procedures to protect other individuals that could be affected by the same deficient practice.
The Clinical Manager will review and sign off all Restrictive Procedure Order and Report Forms to ensure family notification occurred as soon as possible. The Clinical Manager will report their findings to the Director of Residential Services.
The Director of Residential Services will be responsible for ongoing monitoring the corrective action plans.
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 interviews, 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 staff debriefing within 24 hours. This applied to four (#1, #7, #8, and #10) of 10 individuals in the survey sample. Findings included:
1. A record review was completed on June 12, 2024, for Individual #1. This review revealed that Individual #1 was involved in two ESI's on February 23, 2024. This review failed to reveal that all of the staff that participated in the two ESI's on February 23, 2024, also participated in the post-intervention staff debriefings.
2. A record review was completed on June 12, 2024, for Individual #7. This review revealed that Individual #7 was involved in an ESI on February 14, 2024, at 3:21 PM. This review failed to reveal that all of the staff that participated in the ESI on February 14, 2024, also participated in the post-intervention staff debriefing.
3. (a) A record review was completed on June 12, 2024, for Individual #8. This review revealed that Individual #8 was involved in an ESI on May 24, 2024, at 7:32 PM. This review revealed that the post-intervention staff debriefing occurred on May 28, 2024, at 2:14 PM.
3. (b) This review failed to reveal that all of the staff that participated in the ESI on May 24, 2024, for Individual #8 also participated in the post-intervention staff debriefing.
4. A record review was completed on June 12, 2024, for Individual #10. This review revealed that Individual #10 was involved in an ESI on February 23, 2024, at 3:47 PM. This review failed to reveal that all of the staff that participated in the ESI also participated in the post-intervention staff debriefing.
An interview was conducted with the administrator for program compliance (APC) and the administrator for quality services (AQS) on June 13, 2024, at 1:28 PM. The APC and AQS confirmed that for the above mentioned events, not all staff that participated in the ESI's also participated in the post-intervention staff debriefings. The APC and AQS further confirmed that the post-intervention staff debriefing for the ESI involving Individual #8 did not occur within 24 hours.
Plan of Correction:On July 2, 2024, the 4 individuals identified as facilitating the debriefings in the deficiencies were re-educated on the process of debriefing all staff involved in a restrictive procedure. The documentation identified in the deficiency statement could not be corrected for the individuals identified in the deficiency statement as too much time had passed, and the staff members could not accurately discuss the events during those particular restrictive procedures. There was 1 individual who completed a debriefing with all individuals involved in the restrictive procedure; however, this was not completed in the appropriate time frame. The documentation in this deficiency did not need to be corrected as the debriefing included all those involved but was completed outside the time frame.
The quarterly refresher for our training year's quarter 4 (July – September 2024) will include the expectation that leadership makes sure debriefings are completed timely and with all individuals involved in the Restrictive procedure. It will also include the expectation with the direct care staff that they will participate in post restrictive procedure debriefings to protect other individuals that could be affected by the same deficient practice. The Director of Residential Services and Senior Clinical Manager are responsible for developing the curriculum and the Training Department and Therapeutic Crisis Intervention Trainers will be responsible for implementing the training.
The Clinical Manager will review and sign off on all Restrictive Procedure Order and Report Forms to ensure that all individuals involved with the restrictive procedure were debriefed in the appropriate time frame. The Clinical Manager will report their findings to the Director of Residential Services.
The Director of Residential Services will be responsible for ongoing monitoring the corrective action plans.
483.376(b) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Certification in the use of cardiopulmonary resuscitation, including periodic recertification, is required.
Observations:
Based on a review of staff training records and interview, it was determined that the facility failed to ensure that all staff were certified in cardiopulmonary resuscitation (CPR). This applied to three of 183 staff training records reviewed. Findings included:
A review of staff training records in CPR was completed on June 13, 2024. This review revealed that three of 183 staff did not have current certification in CPR.
An interview was conducted with the administrator of quality services (AQS) on June 13, 2024, at 1:15 PM. The AQS confirmed that three staff were not current with their CPR certification.
Plan of Correction:Corrective action was taken on 6/14/24 to train two of the staff members in CPR. One staff member was removed from the schedule until he completed his CPR training on June 26, 2024.
The Training Department runs bi-weekly overdue training reports that leadership receives with the information on which trainings are overdue for their team. In addition, Relias (on line training platform) has been set up so that the manager has access to their entire teams' trainings. Notifications begin at the 30-day mark and continue to send notifications until the trainings are completed. The Training Department will begin to email the overdue Training Report on a weekly basis to the staff, Supervisor and Director of Residential Services and will include an additional reminder to complete their training to protect other individuals that could be affected by the same deficient practice. Any staff member not compliant with their CPR certification will be removed from the schedule.
The supervisor will be responsible for reviewing the weekly report to ensure that no staff are out of compliance. Any staff out of compliance will be reported to the Director of Residential Services, Campus Coordinators and Human Resources Department to be removed from the schedule.
The Director of Residential Services will be responsible for ongoing monitoring the corrective action plans.
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