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 six and the sample consisted of five individuals.
Plan of Correction:
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 in a review of facility records and interview, it was determined that the facility failed to ensure documentation for restraints were completed by the end of the shift that the restraint occurs. This applied to three of 13 restraints reviewed. Findings included:
Record reviews for Individuals #1, 2 and 3, were completed on November 17, 2021. The review revealed that on the following dates the individuals experienced restraints:
Individual #2 September 24, 2021
Individual #3 August 13, 2021
Individual #4 August 27, 2021
Further review of these restraints revealed that the orders for Individuals #'s 2, 3 and 4 were not entered in the records until November 17, 2021. In addition, the documentation for the face to face assessments for Individuals #2 and #4 were also not entered until November 17, 2021.
Interview with the chief operating officer on November 17, 2021, confirmed that the documentation was not completed in a timely manner as required.
Plan of Correction:The Director of Nursing was made aware of the deficiencies in this area. It has been determined that the Director of Nursing or the Assistant Nursing Director will be added a more effective communication and documentation process. When there is a Therapeutic Hold (TH) and a physician order, the Director of Nursing or the Assistant Director of Nursing will be contacted. This contact will include the details of the physician's order.
The addition of the contact regarding the physician's orders will ensure that the Director of Nursing can be review the orders in the client's electronic medical records (EMR) accuracy. The involvement at the beginning of the TH and physician's orders documentation process will ensure that the orders are entered and are correct in a timely manner meeting the regulatory guidance. The EMR system will also send an alert when a nursing "face to face" document is signed.
This additional part of the notification process will be reviewed with all of the nurses during monthly supervision. The changes to the notification process will impact all nursing staff members. The upcoming nursing team staff meetings will provide training regarding the addition of the contact to the Director of Nursing or the Assistant Nursing Director regarding the physical orders for the TH. The Director of Nursing will be responsible for accuracy of the physician's orders. There will be a review of the physician's orders in the client's EMR after every contact from the nursing department or alert from the EMR system by the Director of Nursing or their designee.
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 a review of facility training records, it was determined that the facility failed to ensure all staff participating in restraints are current with safe crisis management (SCM) training. This applied to six staff. Findings included:
A review of staff training records was completed on November 17, 2021. This review revealed that six of 16 staff were not trained semi annually.
Interview with the human resource director on November 17, 2021, at 9:05 AM confirmed that the six staff were not trained 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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