Initial Comments:
A validation survey was conducted August 12, 13 and 16, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities.
Plan of Correction:
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), §485.542(b)(7), §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 review of the facility's emergency preparedness (EP) plan, and interview. It was determined that the facility failed to ensure the plan addressed a waiver declared by the secretary, in accordance with section 1135 of the Act. Findings included:
A review of the facility's EP plan was reviewed on August 12, 2021. This review revealed that the facility failed to address a waiver declared by the secretary, in accordance with section 1135 of the Act.
Interview with the chief operating officer on August 13, 2021, at 9:00 AM confirmed that the the facility's current EP plan did not address a waiver declared by the secretary.
Plan of Correction:Perseus House RTF's Emergency Operations Plan is a living document requiring use and updating. New staff will receive documented training in emergency preparedness policy and procedure within 90 days of hire. It has been prepared by a contracted emergency management agency. Perseus House has contacted the contracting agency to update the plan to address the 1135 waivers under the Social Security Act. The contracted agency and the Associate CEO will make the plan updates by 10/15/21.
All current staff will be trained on the update within 45 days. Human Resources will monitor and track documentation to ensure its completion.
New staff will receive documented training in emergency preparedness policy and procedure within 90 days of hire. The policy will be reviewed annually and prompted by the employee annual training plan. The documentation will be maintained by the Human Resources department and will appear on the New Employee Training Plan and 90 day orientation checklist, as well as the ongoing Annual Employee Training for existing employees.
The plan will address include:
In the case of an emergency or disaster mitigation/or relief requiring the relocation of the residents and staff of Perseus House RTF, Perseus House will comply with the primary emergency management provider in a local, regional, statewide or national emergency. Compliance will include:
-conditions of participation or other certification requirements
-Program participation and similar requirements
-Preapproval requirements
-Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only-state law governs whether a non-Federal provider is authorized to provide services in the state without state licensures)
-Emergency Medical Treatment and Labor Act (EMTALA) sanctions for redirection of an individual to receive a medical screening examination in an alternative location pursuant to a state emergency preparedness plan (or in the case of a public health emergency involving pandemic preparedness plan) or transfer of an individual who has not been stabilized if the transfer is necessitated by the circumstances of the declared emergency. A waiver of EMTALA requirements is effective only if actions under the waiver do not discriminate on the basis of a patient's source of payment or ability to pay.
-Stark self-referral sanctions
-Performance deadlines and timetables may be adjusted (but not waived)
-Limitations on payment to permit Medicare enrollees to use out of network providers in an emergency situation.
-The policy is subject to the requirements of the National Emergencies Act, the Stafford Act, and any declaration issued by the HHS Secretary regarding public health emergencies, or any and all relevant local, state and federal declarations requiring compliance.
441.184(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of facility provided training records and interview it was determined that the facility failed to ensure that all staff are trained on the facility's emergency preparedness (EP) plan. This applied to 9 of 15 staff. Findings included:
Review of facility provided staff training records were completed on August 16, 2021. This
review revealed that 9 staff were not trained on the facility's emergency preparedness (EP) plan.
Interview with the chief operating officer on August 16, 2021, at 9:00 AM, confirmed that there were 9 staff not trained on the facility's emergency preparedness (EP) plan.
Plan of Correction:The Perseus House RTF Emergency Operations Plan must be updated/revised, and exercised annually.
New Perseus House staff will receive documented training in emergency preparedness policy and procedure within 90 days of hire and annually thereafter. The documentation will be maintained by Human Resources and will appear on the New Employee training plan and 90 day orientation checklist for new employees, and the ongoing Annual Employee Training for existing employees.
All current employees will be trained 9/30/21.
The Human Resources department and the Program Supervisor will be responsible for ensuring compliance. Additionally, Emergency Operations training reminders and drills will be added to the Perseus House Safety Team agenda which meets monthly and is comprised of representation from Perseus House RTF.
Initial Comments:
A validation survey was conducted August 12, 13 and 16, 2021, 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 11 and the sample consisted of six individuals. There were no deficiencies.
Plan of Correction:
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