Initial Comments:
A validation survey was conducted July 29, 2019 through August 2, 2019, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was 95 and the sample consisted of ten individuals.
Plan of Correction:
441.184(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on facility documentation and interview, it was determined that the facility failed to develop an emergency preparedness plan/program, that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. This applied to all the residents at the facility. Findings included:
Review of facility provided documentation of the emergency preparedness plan was completed on August 2, 2019. This review revealed the facility failed to establish and develop a facility-based and community-based risk assessment, utilizing an all-hazards approach.
Interview with the administrator of program compliance and the administrator of quality services on August 2, 2019, at 10:00 AM, confirmed that the facility's emergency preparedness plan was developed without a comprehensive all hazards approach risk assessment.
Plan of Correction:On August 5, 2019, The Administrator of Quality Services reached out to three community based organizations (insurance carrier, security agency and a university) to ask for their input and assistance with identifying facility based and community based risks. The Administrator of Quality Services will meet with them to discuss potential risks. On August 20, 2019, The Bradley Center's certified safety committee will utilize an all hazards approach to identify facility and community based risks as well. The information gathered from these meetings will be compiled and ranked by the safety committee. This is scheduled to occur at the September 17, 2019 meeting. Annually or more frequently as needed, there will be an agenda item for for the safety Committee to review the emergency preparedness plan including utilizing an all hazards approach risk assessment. The Administrator of Quality Services, serving as the Safety Committee chairperson will be responsible for monitoring the corrective action.
441.184(b)(5) STANDARD
Policies/Procedures for Medical Documentation
Name - Component - 00
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
*[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.
*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Based on document review and interview it was determined that the facility failed to develop an emergency preparedness plan to include a system of medication documention. This applied to all residents at the facility. Findings included:
A review of facility provided documentation on emergency preparedness was completed on August 2, 2019. This review failed to reveal that the facility developed an emergency preparedness plan to include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
Interview with the administrator of program compliance and the administrator of quality services on August 1, 2019, at 1:00 PM confirmed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records was not included in the emergency plan.
Plan of Correction:The Administrator of Quality Services, in collaboration with the Administrator of Program Compliance, will update the Emergency Preparedness Policy and Plan. This update will include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. These updates will be presented to the Administrative Management Team on September 3, 2019 with final approval from the Executive Steering Committee by September 30, 2019. Annually or more frequently as needed the certified Safety Committee will review the Emergency Preparedness Plan to ensure all components are present including a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This will be documented in the meeting minutes and will be listed on the agenda. The Administrator of Quality Services, serving as the Safety Committee chairperson, will be responsible for monitoring the corrective action.
441.184(b)(8) STANDARD
Roles Under a Waiver Declared by Secretary
Name - Component - 00
§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Based on facility provided documentation and interview it was determined that the facility failed to develop an emergency preparedness plan to include the facilities role under a waiver declared by the Secretary of the Department of Health. This applied to all the residents at the facility. Findings included:
Review of facility provided documentation on August 2, 2019, revealed the facility lacked a written emergency preparedness plan to include the facilities role under a waiver declared by the Secretary of the Department of Health.
Interview with the administrator of program compliance and the administrator of quality services on August 1, 2019, at 1:00 PM confirmed the facility did not have a written emergency preparedness plan to include the facilities role under a waiver declared by the Secretary of the Department of Health.
Plan of Correction:The Administrator of Quality Services, in collaboration with the Administrator of Program Compliance, will update the Emergency Preparedness Policy and Plan to include that The Bradley Center will comply with all waivers declared by the Secretary of The Department of Health. These updates will be presented to the Administrative Management Team on September 3, 2019 with final approval from the Executive Steering Committee by September 30, 2019. Annually or more frequently as needed the certified Safety Committee will review the Emergency Preparedness Plan to ensure all components are present including that The Bradley Center will comply with all waivers declared by the Secretary of The Department of Health. This will be documented in the meeting minutes and will be listed on the agenda. The Administrator of Quality Services, serving as the Safety Committee chairperson, will be responsible for monitoring the corrective action.
441.184(c)(4)-(6) STANDARD
Methods for Sharing Information
Name - Component - 00
§403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.
(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)]
(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).
*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.
*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Based on facility provided documentation and interview, it was determined that the facility failed to develop an emergency preparedness plan to include a method for sharing information and medical documentation. This applied to all the residents at the facility. Findings included:
Review of facility provided documentation on emergency preparedness that was completed on August 2, 2019. This review revealed that the facility failed to develop an emergency preparedness plan to include include a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
Interview with the administrator of program compliance and the administrator of quality services on August 1, 2019, at 1:00 PM, confirmed the facility failed to develop an emergency preparedness plan to include a method for sharing information and medical documentation with other health providers to maintain the continuity of care.
Plan of Correction:The Administrator of Quality Services, in collaboration with the Administrator of Program Compliance, will update the Emergency Management Policy and Plan to include a method for sharing information and medical documentation, as necessary, with other health providers to maintain the continuity of care. These updates will be presented to the Administrative Management Team on September 3, 2019 with final approval from the Executive Steering Committee by September 30, 2019. Annually or more frequently as needed the certified Safety Committee will review the Emergency Preparedness Plan to ensure all components are present including a method for sharing information and medical documentation, as necessary, with other health providers to maintain the continuity of care. This will be documented in the meeting minutes and will be listed on the agenda. The Administrator of Quality Services, serving as the Safety Committee chairperson, will be responsible for monitoring the corrective action.
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), §485.625(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, 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 conduct the required second full scale exercise, or tabletop exercise of the facility's emergency preparedness plan. This applied to all the residents in the facility. Findings included:
Review of facility provided emergency management documentation was completed on August 2, 2019. This review revealed that a full scale exercise of the emergency preparedness plan was completed on November 30, 2018. Further review of the documentation failed to reveal that a second exercise, either a full scale drill or tabletop exercise was also completed within the previous 12 months.
Interview with the administrator of program compliance and the administrator of quality services on August 2, 2019, at 10:00 AM, confirmed that no second emergency preparedness plan exercise was completed by the facility within the previous 12 months.
Plan of Correction:The Administrator of Quality Services along with the Safety Committee will create a schedule for disaster drills that will ensure that 2 drills occur no less than 4 months or greater than 8 months apart to ensure that 2 disaster drills occur annually. One of these drills will be a full scale drill with the other being either a table top or full scale drill. The Safety Committee will be part of the debriefing any time the Emergency Preparedness Plan is utilized regardless if it was a drill or not. Every 6 months, the Safety Committee will evaluate if a drill has been held in the last 6 months. This will be documented in the meeting minutes and will be listed on the agenda. The Administrator of Quality Services, serving as the Safety Committee chairperson, will be responsible for monitoring the corrective action.
Initial Comments:
A validation survey was conducted July 29, 2019, through August 2, 2019, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was 95 and the sample consisted of ten individuals.
Plan of Correction:
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 reviews and interview it was determined that the facility failed to ensure that orders for restraints included a specific length of time permitted by the practitioner. This applied to three (#4, #5, #8) of ten residents in the survey sample. Findings included:
Record reviews were completed for Individuals #4, #5, and #8 on July 31, 2019. The records revealed that these individuals experienced restraints on the following dates:
Individual #4:
March 21, 2019, 2 restraints
Indiviudal #5:
June 15, 2019, 4 restraints
June 16, 2019, 2 restraints
June 17, 2019, 8 restraints
June 20, 2019, 4 restraints
June 24, 2019, 2 restraints
July 7, 2019, 1 restraint
July 25, 2019, 1 restraint
Individual #8:
July 31, 2019, 1 restraint
A review of physician's orders revealed that the nurse failed to document the specific length of time when receiving the orders for these restraints.
An interview was completed with the administrator of program compliance on August 1, 2019, at 10:50 AM. The administrator confirmed that the nurses failed to accurately document the specific lengths of times for the above listed restraints, when the order was obtained from the physician.
Plan of Correction:All Restrictive Procedure Order and Report forms that were identified as not having the length of the order documented will be corrected to include the length of the order. On August 13, 2019 the Nurse Manager communicated with all of the nursing staff that receive orders for restraints to remind them that the length of the restraint ordered by the doctor must be documented on the Restrictive Procedure Order and Report Form. These forms will be audited by the Nurse Manager weekly to ensure that all parts of the order are documented on the form prior to submission to the Medical Records Department. The Nurse Manager will be responsible for monitoring the 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 record reviews and interview it was determined that the facility failed to ensure that all individual debriefings were completed within 24 hours. This applied to two (#8 and #10) of ten residents in the survey sample. Findings included:
1. A record review was completed for Individual #10 on August 1, 2019. This review revealed that Individual #10 was involved in two restraints on April 15, 2019, and the debriefings were completed on April 18, 2019. Individual #10 was involved in a restraint on April 20, 2019, and the individual debriefing was completed on April 24, 2019.
2. A record review was completed for Individual #8 on July 31, 2019. This review revealed that Individual #8 was involved in a restraint on February 20, 2019. There was no documentation indicating that Individual #8 had participated in a debriefing.
Interview with the administrator of quality services and the administrator of program compliance on August 1, 2019, at 10:30 AM confirmed that these debriefings for Individual #10 and #8 were not completed within 24 hours.
Plan of Correction:For individual #8 that did not have documentation that a debriefing occurred following a restraint on February 20, 2019. Her therapist will conduct a debriefing during her individual therapy session the week of August 26, 2019. On August 7, 2019 the Director of Residential Services met with the Clinical Managers to reiterate that the Life Space Interview (debriefing) following a restrictive procedure can be completed up to 24 hours after its completion. If a resident refuses to participate in the first attempt to complete the Life Space Interview, additional attempts need to be made and documented. On August 15, 2019, this information was also communicated to all positions that can act as the Clinician on Call. This information will be communicated to all clinical staff during the unit staff meetings due to be held in September. Any child that refuses any attempts to complete a Life Space Interview during the shift that the restrictive procedure occurred will be included in the Clinician on Call Log as well as the Unit Shift Note to alert the staff on the next shift that attempts to conduct the Life Space Interview should be made and documented. The Clinical Manager reviews and signs off on all Restrictive Procedure Order and Report Forms weekly. The Clinical Manager will be responsible for monitoring the corrective action.
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