Initial Comments:
A validation survey was conducted November 15-18, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted November 15-18, 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.
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 a review of restraint documentation and interview, it was determined that the facility failed to ensure that a specified length of time for a restraint ordered by the physician was not exceeded. This applied to one of ten restraints reviewed. Findings included:
Documentation reviewed revealed Individual #1 experienced a restraint on November 3, 2021, that lasted for 15 minutes. The order given by the physician for this restraint was not to exceed six minutes. There was no documentation that another order was received to extend the restraint
An interview was conducted with the director of nursing (DON) on November 17, 2021, at 9:35 AM. The DON confirmed that the restraint lasted longer than what the physician ordered and a new order had not been obtained.
Plan of Correction:To ensure accuracy of the physician's orders, contact will be made to the Director of Nursing or the Assistant Nursing Director when a nurse receives an order from the physician. This contact will include information regarding the details of the physician's order. The nurse that receives the order from the physician will communicate the length of time for the Therapeutic Hold (TH) to the Director of Nursing, the Assistant Nursing Director and the facility Program Supervisor. This contact will ensure that all of the individuals involved in the TH and the documentation process have the correct information.
It has been determined that this information and process will be reviewed with all of the nurses during monthly supervision. Upcoming nursing team staff meetings will address the addition of the communication/contact regarding the physician's orders for the TH.
The Director or Nursing and the Assistant Nursing Director will review the nursing documentation to ensure the accuracy of the nursing Face to Face documentation with the physician's orders. The Clinical Director will review the facility staff documentation regarding the TH to ensure accuracy when compared to the physician's orders.
483.358(h) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Staff must document the intervention in the resident's record. That documentation must be completed by the end of the shift in which the intervention occurs. If the intervention does not end during the shift in which it began, documentation must be completed during the shift in which it ends. Documentation must include all of the following:
Observations:
Based on record review and interview it was determined that the facility failed to ensure that documentation for restraints were completed by the end of the shift that the restraint occurred. This applied to one (#1) of three individuals in the survey sample that had been restrained. Findings included:
A review of documentation of six restraints for Individual #1 was completed on November 17, 2021. This review revealed that orders for four of these restraints were not entered in the record until November 17, 2021. In addition, the face to face assessments by the nurse was not completed by the end of the nurses shift. The dates of the four restraints were September 13, 2021, at 6:50 PM; September 24, 2021, at 9:35 PM; November 2, 2021, at 8:03 PM; and November 2, 2021, at 9:43 PM.
Interview with the director of nursing on November 17, 2021, at 9:30 AM, confirmed that the documentation was not completed in a timely manner as required.
Plan of Correction:When a nurse receives the physician's order, contact will be made to the Director of Nursing or the Assistant Director of Nursing. This contact will be from the nurse that has received the Therapeutic Hold (TH) physician's order. Once the contact is made, Director of Nursing or the Assistant Nursing Director will verify the required documentation is inputted into the client's medical records system (EMR). Once the nursing face to face documentation is inputted into the EMR, an alert is be generated to the Director of Nursing. These two steps will allow immediate review of the physician's orders for accuracy and timeliness of the documentation that is inputted by the assigned nurse.
It has been determined that this information and process will be reviewed with all of the nurses during monthly supervision. The upcoming nursing team staff meetings will address the addition of the required contact regarding TH and physician's orders.
The Director of Nursing and the Assistant Nursing Director will be responsible for ensuring that these notifications are occurring to ensure accurate and documentation within the regulatory standards.
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 a record review and interview it was determined that the facility failed to ensure that a face to face discussion was conducted with a resident within 24 hours after the use of a restraint. This applied to one of ten restraints reviewed. Findings included:
Record review for Individual #1 was completed on November 16, 2021. This review revealed that Individual #1 had experienced a restraint on September 13, 2021, that lasted six minutes. This review failed to reveal that a face to face discussion was conducted with Individual #1.
An interview was conducted with the chief operating officer (COO) on November 17, 2021, at 10:50 AM. The COO confirmed that a face to face discussion was not conducted with Individual #1 following the restraint on September 13, 2021.
Plan of Correction:After a Therapeutic Hold (TH) occurs, contact is made with the Program Supervisor. It is this initial contact that will ensure that the debriefing process begins. The debriefing process will include, the precipitating factors and the situations that led to the TH, and any other possible strategies or interventions that could be employed to avoid a future TH. The Program Supervisor will review the debriefing process with the staff during the initial contact so that the client debriefing occurs.
Following the TH and prior to the end of the staff's shift, the Therapeutic Restraint Special Incident Report (SIR) will be completed by the facility staff. The client's initial debriefing is to be documented in this area in the EMR. Once the lead staff have signed the SIR in the client's EMR, an alert to the Program Supervisor, the Clinical Director and the COO will be automatically sent. This alert will function as a way to follow and track the progress of the SIR process and the debriefing timeframe. It will be the Program Supervisor's responsibility to review the SIR and ensure that the debriefings have occurred correctly and in accordance with regulatory timeframe standards.
All Perseus House staff are responsible for understanding and utilizing this process and timeframe. The Program Supervisors will review and be trained on this process at the next Perseus House Executive Committee/Quality Council (EC/QC) meeting by the COO and the Clinical Director. The EC/QC meeting minutes are sent electronically to all PH staff members. The Program Supervisors conduct regular staff meetings for their facilities and the EC/QC meeting minutes are reviewed. The Clinical Director is present at both the EC/QC and staff meetings for clarification of the process and expectations. These identified areas of information sharing will confirm that all Perseus House staff have the information necessary to meet the timeframe standards.
The COO and the Clinical Director will be responsible for following the EMR alerts and the Therapeutic Hold notifications. The COO and Clinical Director and/or their designee will review the process and improvement with meeting the standards for debriefing timelines.
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 a record review and interview, it was determined that the facility failed to ensure that all staff involved in a restraint, participated in a debriefing within 24 hours after the intervention. This applied to one individual (#1) out of three in the sample that had been restrained. Findings included:
A record review for Individual #1 was completed on November 16, 2021. This review revealed that Individual #1 was restrained on September 13, 2021, at 6:50 PM for six minutes and on September 18, 2021 for 5 minutes. This review failed to reveal documentation that the staff participating in both restraints participated in a debriefing session within 24 hours of the restraints.
An interview was conducted with the chief operating officer (COO) on November 17, 2021, at 9:05 AM. The COO confirmed that the staff debriefing sessions for Individual #1 were not completed.
Plan of Correction:The current notification process after any Therapeutic Hold is the facility staff make an initial notification to the Program Supervisor or his/her/their designee to inform of the Therapeutic Hold (TH) The Program Supervisor or designee will then debrief the staff involved after the initial notification. This debrief will occur either in person or on the phone. If the debrief cannot occur as a group with all of the involved staff present then the facility supervisor and/or the designee will debrief each staff within 24 hours from the TH start time individually, either in person or on the phone. Both of the debriefings will occur within 24 hours of the therapeutic hold.
The expectation is that the Therapeutic Hold Special Incident Report (SIR) is to be completed by the lead staff at the facility prior to the end of their shift. Once the SIR is completed in the client's electronic medical records, an alert is sent to the Program Supervisor. Once the Program Supervisor receives this alert, a review will occur to ensure that the debriefings have occurred or will make a plan to ensure that they do occur in a timely manner. This alert will serve as another reminder to ensure that the two debriefings from the Therapeutic Hold have been completed.
To ensure that this standard is followed, the Perseus House Chief Operating Officer (COO), will review the process at a scheduled Executive Committee/Quality Committee (EC/QC) meeting. It is the standard expectation that all of the information that is reviewed at the EC/QC meetings are then reviewed at the facility staff meetings and provided to staff in the communication logs. This will ensure that all staff are aware of the regulatory time frames
483.376(f) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis.
Observations:
Based on review of facility provided training records and interview, it was determined that the facility failed to ensure that all staff were trained in safe crisis management (SCM) on a semi annual basis. This applied to two of 11 staff. Findings included:
Review of facility provided staff training records were completed on November 17, 2021. This review revealed that two staff were not trained on the facility's safe crisis management program on a semi annual basis.
A interview was conducted with the human resource (HR) director on November 17, 2021, at 9:05 AM. The HR director confirmed there were two staff not trained in SCM on a semi annual basis.
Plan of Correction:
Perseus House has the following process in place to ensure that staff are trained in Safe Crisis Management (SCM) techniques to meet the standards and guidelines of all licensing/governing entities/agencies:
There is monthly training in SCM for new hires to Perseus House
There is a scheduled semi - annual SCM refresher
There is an annual SCM refresher
There are Quarterly Skill Outs that are offered
The training calendar with all of these SCM training opportunities and reminders are forwarded to Program Supervisors regarding SCM training opportunities by individuals in the Human Resources HR department on a monthly or as needed basis.
Perseus House utilizes an online training platform, Relias. Relias will track trainings and provide alerts to the staff, the Program Supervisors and the designated HR individual. This alert will ensure that staff are trained within the regulatory guidelines. It will also allow supervisors to ensure that the staff that are not trained at least semi-annually will not be participating in any Therapeutic Holds (TH).
Perseus House HR Director and their designee has provided and will continue to provide training to all Perseus House staff and supervisors to ensure the effective utilization Relias in regard to SCM. All Perseus House staff are responsible for understanding their SCM training requirements. The Program Supervisors will review and be trained on this process at the next Perseus House Executive Committee/Quality Council (EC/QC) meeting by the HR Director or their designee. The EC/QC meeting minutes are sent electronically to all PH staff members. The Program Supervisors conduct regular staff meetings for their facilities and the EC/QC meeting minutes are reviewed. The HR Director is present at the EC/QC meetings for clarification of the process and expectations. This information sharing will confirm that all Perseus House staff have the information necessary to meet the timeframe standards.
The addition of Relias as well as the HR training tracking and updates will help to ensure that all staff are SCM trained to meet the standard of a semi-annual basis. The HR Director will be responsible to ensure that communication regarding staff's need for SCM training is occurs and is completed. The COO will coordinate with the HR Director to support the corrective action plan to ensure compliance with semiannual SCM training.
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