Initial Comments:
A recertification survey visit was conducted on March 24 through 25, 2021. 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 Foundations Behavioral Health/Perseverance 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:
A recertification survey visit was conducted on March 24 through 25, 2021. 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 residents under the age of 21. The census at the time of the visit was 13, and the sample consisted of six residents.
Plan of Correction:
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 and #3.
Findings include:
A review of the records for Resident #1 and #3 on 03/24/2021 and 03/25/2021 between 9:00 AM and 11:00 AM revealed the following;
Resident #1
A review of the record of Resident #1 revealed that she had been restrained on 01/30/2021. This incident was documented on an restrictive intervention order packet. This restrictive intervention order packet revealed that the ESI was initiated at 11:45 AM and discontinued at 12:00 PM. Continued review of this restrictive intervention order packet revealed that the one hour assessment of the physical and psychological well-being was conducted at 11:30 AM, 15 minutes prior to the start of this restraint.
Resident #3
A review of the record of Resident #3 revealed that she had been restrained on 10/26/2020. This incident was documented on an restrictive intervention order packet. This restrictive intervention order packet revealed that the ESI was initiated at 5:32 PM and discontinued at 5:50 PM. Continued review of this restrictive intervention order packet revealed that the one hour assessment of the physical and psychological well-being was conducted at 6:15PM beyond the one hour assessment time period, from initiation of the restraint.
Interview with the Director of Compliance & Physician Relations on 03/25/2021 at approximately 10:00 AM confirmed the that the above mentioned one hour assessments were not conducted within one hours of the initiation of the restraint.
either conducted before the restraint and/or conducted late.
Plan of Correction:1. Following the recertification validation audit for Perseverance Hall on 3/25/2021, Foundations Behavioral Health leadership team members met to review the findings, policy and standards and develop a plan of action specific to the Face to Face assessment requirements. The meeting was facilitated by the Director of Compliance and in collaboration with the facility Interim CEO. In order to assure ongoing compliance with face to face assessments, data will continue to be reviewed bi-weekly during Executive Leadership Meeting, led by the CEO and Hospital Administrator.
2. Training on the elements of restrictive interventions in accordance with policy and standard was initiated on 3/26/2021 by RN Leadership Staff led by the Chief Nursing Officer. This training focused on elements of the Face to Face assessment completion requirements to be completed post intervention within 1 hour from initiation of the restrictive intervention. Nursing Staff providing care within Perseverance Hall and within all other accredited PRTF programs within the facility, received in person instruction on these three elements, with training initiated on 3/26/2021 and will be completed on or before 4/13/2021. For those staff members that were not able to be trained due to unavailability, training will be required before their next worked shift.
3. Given the oversight and management required by the RN in restrictive interventions, a separate formal training was developed by RN leadership led by the Chief Nursing Officer, initiated on 4/5/2021 to be concluded on or before 4/13/2021 via HealthStream, the facility's web-based training portal. Training was specific to those RNs providing care within Perseverance Hall as well as within other accredited PRTF programs within the facility. Educational materials focused on face to face assessment completion requirements to be completed post intervention within 1 hour from initiation of the restrictive intervention. For those RNs that were not able to complete the formal training due to unavailability, training will be required before their next worked shift.
4. Initiated on 3/26/2021, RN Supervisors, led by the Chief Nursing Officer, are now notified by unit RNs each time a restrictive intervention is initiated applicable to Perseverance Hall as well as all other PRTF programs within the facility. This live, real-time notification allows for supervisory support and oversight in properly completing the Face to Face assessment according to policy and standard. RN supervisory oversight remains current and ongoing. Deficiencies noted during this review process shall be brought to the attention of the Chief Nursing Officer for appropriate follow up, including disciplinary action as warranted. Information and data collected by the RN Supervisors to the Chief Nursing Officers on face to face assessment documentation compliance will be collected, reviewed and analyzed monthly using an overall percentage of compliance. Data will be presented monthly to Performance Improvement and Medical Executive Committee and quarterly update to the Board of Governors.
5. As an additional measure of monitoring and sustainability, 100% of all restrictive interventions for Perseverance Hall and all PRTF facility programs for the next 3 months shall be reviewed by the facility compliance team, led by the Director of Compliance. Data points on compliance with the face to face assessment requirements. The use of data related to compliance with the Face to Face assessment requirements will be collected monthly using overall percent compliance and graphical depictions for trending and tracking purposes. Should sustainability in the aforementioned areas of focus be above 90% compliance following 3 months of 100% reviews, consideration will be given to reduction in the sample size from 100% to 50%. Data will be presented monthly to Performance Improvement and Medical Executive Committee and quarterly update to the Board of Governors.
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 with administrative staff the facility failed to ensure that within 24 hours after the use of restraint, staff involved in an emergency safety intervention and the resident must have a face to face discussion. This practice is specific to Resident #1, and #5.
Findings include:
A review of the records for Resident #1 and #5 was completed on 03/24/2021, between 9:00 AM and 11:00 AM, and revealed the following:
Resident #1
Resident #1 was restrained on 12/11/2020. This incident was documented on a restrictive intervention order packet which documents all aspects of an ESI. The restrictive intervention order packet indicates that the ESI was initiated at 7:00 PM and discontinued at 7:10 PM. The client debriefing listed all the staff involved in the ESI. However the debriefing occurred on 12/11/2020 at 7:00 PM, the exact time the ESI was initiated.
Resident #1 was restrained on 1/22/2021. The restrictive intervention order packet indicates that the ESI was initiated at 5:45 PM and discontinued at 6:00 PM. The client debriefing listed all the staff involved in the ESI. However, the debriefing occurred on 1/22/2021 at 6:45 PM, the exact time the ESI was initiated.
Resident #1 was restrained on 01/30/2021. This incident was documented on a restrictive intervention order packet which documents all aspects of an ESI. The restrictive intervention order packet indicates that the ESI was initiated at 11:45 AM and discontinued at 12:00 PM. The client debriefing listed all the staff involved in the ESI. However the debriefing occurred on 01/30/2021 at 11:30 AM, 15 minutes before the initiation of the restraint.
Resident #5
Resident #5 was restrained on 12/29/2020. This incident was documented on a restrictive order packet which documents all aspects of an ESI. The restrictive intervention order packet indicates that the ESI was initiated at 8:06 PM and discontinued at 8:11 PM. The client debriefing listed all the staff involved in the ESI. However, the debriefing occurred on 12/29/2020 at 8:07 PM, which was during the time Resident #5 was in the restraint.
Interview with the Director of Compliance & Physician Relations on 03/25/2021, at approximately 10:30 AM, confirmed that per facility policy, the debriefings for Resident #1 and #5 should have occurred after the resident was released from the restraint, not before and/or during the restraint.
Plan of Correction:1. Following the recertification validation audit for Perseverance Hall on 3/25/2021, Foundations Behavioral Health leadership team members met to review the findings, policy and standards and develop a plan of action specific to patient debriefings. The meeting was facilitated by the Director of Compliance and in collaboration with the facility Interim CEO. In order to assure compliance with staff and patient debriefings, data will continue to be reviewed bi-weekly during Executive Leadership Meeting, led by the CEO and Hospital Administrator.
2. Training on the elements of restrictive interventions in accordance with policy and standard was initiated on 3/26/2021 by RN Leadership Staff led by the Chief Nursing Officer. This training included patient debriefing requirements including timeliness within 24 hours after the restraint episode, rather than during restraint episode. Mental Health Technicians and Nursing staff members providing care within Perseverance Hall and within other accredited PRTF programs within the facility, received in person instruction on patient debriefing with training initiated on 3/26/2021 and will be completed on or before 4/13/2021. For those staff members that were not able to be trained due to unavailability, training will be required before their next worked shift.
3. Given the oversight and management required by the RN in restrictive interventions, a separate formal training was developed by RN leadership led by the Chief Nursing Officer, initiated on 4/5/2021 to be concluded on or before 4/13/2021 via HealthStream, the facility's web-based training portal. Training was specific to those RNs providing care within Perseverance Hall as well as within other accredited PRTF programs within the facility. Educational materials focused on policy and standard for patient debriefing requirements including timeliness within 24 hours after the restraint episode, rather than during restraint episode. For those RNs that were not able to be trained due to unavailability, training will be required before their next worked shift.
4. Initiated on 3/26/2021, RN Supervisors, led by the Chief Nursing Officer, are now notified by unit RNs each time a restrictive intervention is initiated applicable to Perseverance Hall as well as all other PRTF programs within the facility. This live, real-time notification allows for supervisory support and oversight in properly completing the patient debriefing in accordance with policy and standard. Supervisory oversight remains current and ongoing. Deficiencies noted during this review process shall be brought to the attention of the Chief Nursing Officer for appropriate follow up, including disciplinary action as warranted. Information and data collected by the RN Supervisors to the Chief Nursing Officers on compliance with patient debriefings will be collected, reviewed and analyzed monthly using an overall percentage of compliance. Data will be presented monthly to Performance Improvement and Medical Executive Committee and quarterly update to the Board of Governors.
5. As an additional measure of monitoring and sustainability, 100% of all restrictive interventions for Perseverance Hall and all PRTF facility programs for the next 3 months shall be reviewed by the facility compliance team, led by the Director of Compliance. The use of data specific to patient debriefing compliance will be collected monthly using overall percent compliance and graphical depictions for trending and tracking purposes. Should sustainability in patient debriefings be above 90% compliance following 3 months of 100% reviews, consideration will be given to reduction in the sample size from 100% to 50%. Data will be presented monthly to Performance Improvement and Medical Executive Committee and quarterly update to the Board of Governors.
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