Initial Comments:
A recertification survey visit was conducted on August 23 through August 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 Silver Springs/Martin Luther Schools 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 August 23 through August 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 57 and the sample consisted of 12 residents.
Plan of Correction:
483.362(a) STANDARD
MONITORING DURING AND AFTER RESTRAINT
Name - Component - 00
Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention.
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention. This practice is specific to Residents #3 and #4.
Findings include:
Resident #3:
1. A review of the record of Resident #3 was completed on 08/23/2021 between 9:00 AM and 11:00 AM. This review noted that Resident #3 had been restrained on 02/17/2021 at 6:15 PM to 6:37 PM, a duration of 22 minutes, using the following restraint types during this time period; "Seated/Kneeling Upper Torso Assist", "Multiple Person Supine Extension", and "Single/Multiple Person Upper Torso Assist". This restraint was documented on a electronic form titled "Incident-Restraint Required v3.0". Under the section titled "Restraint Observation" it notes that the observation was completed 30 minutes after the restraint was initiated. There is no documented evidence that Resident #3 was continually assessed for physical and psychological well-being, and the safe use of the restraint throughout the duration of this Emergency Safety Intervention (ESI) until after the restraint had ended.
Interview with the Vice President of Residential Services on 08/23/2021 at approximately 11:00 AM confirmed the observation was not done until the after the restraint had ended.
2. A review of the record of Resident #3 was completed on 08/23/2021 between
9:00 AM and 11:00 AM. This review revealed Individual #3 had been restrained on 08/16/2021 at 8:00 PM until 8:19 PM, for a duration of 19 minutes. This restraint was documented on a electronic form titled "Incident-Restraint Required v3.0". Under the section titled Restraint Observation there was no documented evidence that clinical staff trained were physically present, continually assessing and monitoring Resident #3 for his physical and psychological well-being, and the safe use of the restraint throughout the duration of this Emergency Safety Intervention (ESI).
Interview with the Vice President of Residential Services on 08/23/2021 at approximately 11:00 AM confirmed that there was no documentation of continually assessing, and monitoring the physical and psychological well-being of the resident including the safe use of restraint throughout the duration of the emergency safety intervention.
Resident #4:
A review of the record of Resident #4 was completed on 08/23/2021 between
9:00 AM and 11:00 AM. This review revealed Resident #4 had been restrained on 07/09/2021 starting at 1:07 PM and ending at 1:55 PM, for a duration of 48 minutes.
This restraint was documented on a electronic form titled "Incident-Restraint Required v3.0". Under the section titled Restraint Observation, it was noted that observation was completed "at 10 minutes." There was no evidence that additional observations were completed during the duration of the restrain action.
An interview with the Vice President of Program Integrity was completed on 08/24/2021 at approximately 10:50 AM. This interviewee confirmed that there is no further documentation to indicate that clinical staff trained was continually assessing, and monitoring the physical and psychological well-being of Resident #4 .
Plan of Correction:El 1. The restraints that are noted in the observations have already occurred and the documentation cannot be edited to add the continuous observations that may have occurred at that time.
El 2. A sample of 10% of all restraints that have occurred in 2021 (with sample size no less than 10 incidents) will be reviewed by the VP of Program Integrity to determine the potential pervasiveness of this deficiency. This will be completed by 10/31/2021. The corrective action will apply to the entire PRTF program.
El 3. All Executive On-Duty staff will be retrained in expectations for ensuring full completion of documentation related to restraints, including clearly documenting an assessment of the youth at least every 10 minutes by the VP of Program integrity no later than 9/30/2021. The digital form that is completed will also be modified by 10/31/2021 to prompt and capture this information clearly.
El 4. The Quality Assurance manager will audit a sample (at least 10% (but no less than 5 incidents) of completed restraint documentation on a monthly basis for compliance of the continuous observation occurring during all restraints. This will occur by the 15th each month and findings submitted to the VP of Residential Services.
El 5. The Vice President of Program Integrity is responsible for the training. The VP of Residential Services is responsible for reviewing the audit findings and ensuring adherence to the requirement. The QA Manager is responsible for completing the audit and reporting back to the VP of Residential for necessary intervention.
483.362(b) ELEMENT
MONITORING DURING AND AFTER RESTRAINT
Name - Component - 00
If the emergency safety situation continues beyond the time limit of the order for the use of restraint, a registered nurse or other licensed staff, such as a licensed practical nurse, must immediately contact the ordering physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion to receive further instructions.
Observations:
Based on a record review and interview with administrative staff, the facility failed to ensure that if the emergency safety situation continues beyond the time limit of the order for the use of restraint, a registered nurse or other licensed staff, such as a licensed practical nurse, must immediately contact the ordering physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion to receive further instructions.
This practice is specific to Resident #4.
Findings included:
A record review for Resident #4 was completed on 08/23/2021 between 9:00 AM and 11:00 AM. This review revealed the following information:
A review of the record of Resident #4 revealed that he had been restrained on 07/09/2021. This incident was documented on a electronic form titled "Incident-Restraint Required v3.0". Under the Restraint Details section of the Incident-Restraint Required v3.0 electronic form, which notes that the physical restraint was initiated at 1:07 AM and discontinued at 1:55 PM, lasting forty-eight (48) minutes.
Continued review of this electronic restraint form revealed that under the Psychiatric Consultation and Restraint Order Information section of this form, it was noted that this restraint was ordered by a licensed practitioner at 1:55 PM for a thirty (30) minute period. Further review of this electronic form revealed there was no documented evidence that a registered nurse or other licensed staff received further instructions, from the ordering licensed practitioner, for the continuation of this restraint past the initial restraint order of thirty (30) minutes.
An interview was conducted with the Vice President of Program Integrity on
8/24/2021 at 10:50 AM. This interviewee confirmed that the psychiatrist was not consulted for further instruction after thirty (30) minutes.
Plan of Correction:El 1. The resident noted in the observation was in a restraint on 8/24/21. This documentation is already locked for editing, so additional information about the hold order or updates may not be added at this time.
El. 2 A sample of 10%, but no less than 10 incidents, of restraints occurring in 2021 by the VP of Program Integrity to determine the pervasiveness of this deficiency. This will occur by 10/31/2021. The plan of correction will be for the entire PRTF program.
El. 3 All hold orders are maintained in the Healthcare Office and members of the Healthcare Office enter the duration approved for the restraint. For restraints that extend beyond the initial order, a second order must be obtained to continue the restraint. The Healthcare Office will enter the total time of orders on the CIR and not just the initial order. The Director of Healthcare will review/retrain the Healthcare Office on this correct process no later than 9/30/2021. The CIR is also being revised to be able to capture the full time plus any additional supporting documentation for the correct order information. This will occur no later than 11/30/2021.
El 4. The Quality Assurance Manager will audit a sample of 10% of completed restraint documentation (but no less than a sample size of 5 incidents) on a monthly basis to ensure compliance with length of restraint ordered to be consistent with the actual length of the hold implemented. This will occur by the 15th of each month and findings submitted to the VP of Residential Services.
El 5. The QA Manager will document the audit results and submit to the VP of Residential Services on a monthly basis to ensure compliance and any follow-up interventions necessary.
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 review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session to discuss the precipitating factors that lead up to the intervention. This practice is specific to Resident #2, #8 and #9.
Findings include:
A review of the records for Resident #2, #8 and #9 was completed on 08/23/2021, between 9:00 AM and 12:00 AM, and revealed the following information:
Resident #2
1. A review of the record of Resident #2 revealed that he had been restrained on 08/20/2021. This incident was documented on a electronic form titled "Incident-Restraint Required v3.0". The electronic restraint form indicates that a multiple person supine extension restraint was initiated at 12:30 PM and discontinued at 12:36 PM. Under the Participants section of this electronic restraint form it list five staff were involved in this restraint. Under the Administrative Debriefing section of this electronic form it list the staff involved in the restraint, however it notes that none of the staff involved in the restraint attended the debriefing and the listed debriefing discussion points on this form are blank.
Interview with the Vice President of Residential Services on 08/23/2021 at approximately 11:30 AM confirmed that the staff/supervisory debriefing was not completed.
Resident #8
A review of the record of Resident #8 revealed that he had been restrained on 07/16/2021. This incident was documented on a electronic form titled "Incident-Restraint Required v3.0". The electronic restraint form indicates that a multiple person supine extension restraint was initiated at 9:59 AM and discontinued at 10:07 AM. Under the Participants section of this electronic restraint form it list four staff were involved in this restraint. Under the Administrative Debriefing section of this electronic form it notes that one staff, involved in the restraint, was present for this debriefing. There is no explaination as to why the other three staff were not in attendance for this debriefing.
Resident #9
A review of the record of Resident #9 revealed that he had been restrained on 03/18/2021. This incident was documented on a electronic form titled "Incident-Restraint Required v3.0". The electronic restraint form indicates that a seated/kneeling cradle assist restraint was initiated at 10:52 AM and discontinued at 10:56 AM. Under the Participants section of this electronic restraint form it list four staff were involved in this restraint. Under the Administrative Debriefing section of this electronic form it notes that one staff, involved in the restraint, was present for this debriefing. There is no explaination as to why the other three staff were not in attendance for this debriefing.
Interview with the Vice President of Residential Services, on 08/23/2021, at approximately 11:00 AM confirmed that all staff were not present for the above mentioned briefing and that no explaination was given for the staff's absences at the supervisor/staff debriefing.
.
Plan of Correction:El 1. Staff involved in the restraints for Residents #2, 8 and 9 that did not participate in the formal de-briefing or their de-briefing was not included in the documentation will participate in a de-briefing with a supervisory staff by 09/30/2021. As the CIR is locked for editing, the de-briefing will not be added to the CIR, but documented in supervision.
El.2 The VP of Program Integrity will review a sample of 10% of restraints in 2021, but no fewer than 10 incident, to determine the pervasiveness of this deficiency. This will occur by 10/31/2021. The plan of correction will apply to the entire PRTF program.
El. 3 The residential program has established a restraint reduction committee that has been focused on revising the de-briefing process to be timely and meaningful. The Executive On-Duty staff will be retrained in the revised expectations which will include requiring that all staff that participated in the restraint participate in the de-briefing. If there are any urgent issues or contraindications (such as a safety plan) that would prevent the staff from participating at that time, this information will be clearly documented on the de-briefing form and will participate prior to working with the youth in the restraint. The field will be modified to require input of this information if noted that a staff was not present. The training will occur no later than 10/15/2021 and the form will be updated by the VP of Residential Services no later than 10/31/2021.
El. 4 The VP of Residential Services is responsible for ensuring the program's adherence to these requirements. The Quality Assurance Manager will complete an audit of a sample of the completed restraint documentation on a monthly basis. The sample size will be at least 10% of restraints that occurred that month, but no fewer than 5 incidents. This will be completed by the 15th of each month and the findings will be submitted to the VP of Residential Services.
El. 5 The QA Manager will document the findings of the audit for complete de-briefings and submit to the VP of Residential Services on a monthly basis for follow-up and additional interventions, if necessary.
483.374(b) ELEMENT
FACILITY REPORTING
Name - Component - 00
Reporting of serious occurrences.
The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State designated Protection and Advocacy system.
Serious occurrences that must be reported include;
- a resident's death;
- a serious injury to a resident as defined in section §483.352 of this part; and
- a resident's suicide attempt.
(1) Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include
- the name of the resident involved in the serious occurrence,
- a description of the occurrence and,
- the name, street address, and telephone number of the facility.
Observations:
Based on record review and interview with the administrative staff, the facility failed to report each serious occurances involving residents to the state designated Protection and Advocacy system for three of four sample Residents who experienced a serious occurrence.
This practice is specific to Resident #6, #11 and #12.
Findings include:
A review of incident reports for the period from February 2021 through August 2021
was completed on 08/24/2021 between 11:00 AM and 12:00 PM. This review
revealed that of the four sample residents who were identified as sustaining a serious occurrence, three sample residents sustained hand fractures during this time period that were not reported to the state designated Protection and Advocacy system.
Individual #6 is exemplary of this practice
Resident #:6 :
A review of an incident report dated 05/21/2021, noted that at 10:47 AM and again at
12:27 AM, Resident #6 complained of both right forearm pain and right wrist pain.
The facility documented on this incident report that "[Resident #6] did not state that the injury was from the [restraint] and therefore did not attribute this injury to the restraint."
At approximately 5:30 PM, this resident was then sent to a local urgent care center to be evaluated and was subsequently diagnosed with subluxation/dislocation and fracture of the [right] distal ulna (A partial displacement of bones that normally have contact with each other, but retaining some contact with each other. The joint is located at the wrist between the ulna and the radius which are the bones of the forearm.).
Further review of this Resident's record revealed no evidence that the state designated Protection and Advocacy system had been notified of this serious occurrence.
An interview was conducted with the Vice President of Program Integrity on 8/24/2021 at 10:30 AM in which this interviewee confirmed that the State designated Protection and Advocacy system had not been notified of this serious occurrence.
Plan of Correction:El 1. As the reporting period for the incidents related to resident 6, 11 and 12, there no corrective action to be taken to correct a deficiency that occurred in the past.
El. 2 The VP of Program Integrity will conduct an audit of 25% of all incidents categorized as serious injury in past 6 months to determine the pervasiveness of this deficiency. This will be completed by 10/31/2021. The plan of correction will apply to the entire PRTF program.
El. 3 The Vice President of Residential Services is retraining the Executive On-Duty staff on the definition of Serious Injury per the Department of Health to ensure that they are fully aware of the expectation to report any injuries meeting that criteria to our designated protection and advocacy system. This will occur no later than 9/30/2022.
El. 4 The Vice President of Program Integrity will be responsible for reviewing the entire (100%) report of serious incidents on a weekly basis to ensure that any incidents meeting criteria for serious injury are correctly reported.
El. 5 The VP of Program Integrity will document the findings of the weekly review and submit them to the VP of Residential Services by the following Wednesday of each week, as well as to the Executive on-Duty so that immediate action to report the occurrence can occur. This will begin on 10/1/2021.
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