Initial Comments:
A validation survey was conducted July 8-12, 2024, to determine compliance with the requirements of the 42 CFR Part 441, Subpart D Regulations for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census during the survey was six and the sample consisted of four individuals.
Plan of Correction:
441.184(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of facility provided staff training records and interview, it was determined that the facility failed to provide training to all staff regarding the facility's emergency preparedness plan (EPP) at least every two years. This applied to 10 of 10 staff at the facility. Findings included:
A review of facility provided staff training records, for staff hired more than two years ago, was completed on July 12, 2024. This review failed to reveal training documentation for 10 staff on the EPP at least every two years.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:07 AM. The DRS confirmed that the facility had no documentation that these 10 staff were trained at least every two years in the EPP.
Plan of Correction:All YTC employees will review the Journey Emergency Preparedness Plan (EPP) as well as the site specific EPP with their supervisor.
-All new BLBHS residential employees will review the Journey Emergency Preparedness Plan (EPP) as well as their site specific EPP during Basecamp Orientation (1st week of employment). An attestation will be loaded into Relias upon completion for verification.
-Training plans will be updated to require all BLBHS residential employees to review the Journey EPP as well as their site specific EPP on a yearly basis in perpetuity, with an attestation for verification.
-Relias transcripts and training reports will be reviewed to ensure compliance during monthly safety meeting.
Annually, all residential employees will review the Journey Emergency Preparedness plan as well as their site specific Emergency Preparedness plan.
-This will be an ongoing activity. Adherence to this plan will be monitored by Director of Residential Services during The Agency's Safety Committee Meeting on a monthly basis, and verified via this committee's minutes and Relias training transcripts.
-Corrective Action will be completed by 1/1/2025.
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 staff training records and interview, it was determined that the facility failed to ensure that all staff were initially trained on the facility's emergency preparedness plan (EPP). This applied to five of 17 staff. Findings included:
Review of facility provided training records for staff that were hired in the past two years, was completed on July 12, 2024. This review failed to reveal documentation that five staff were initially trained on the facilities EPP.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:08 AM. The DRS confirmed that there was no documentation that the five staff were initially trained on the facility's EPP.
Plan of Correction:All YTC employees will review the Journey Emergency Preparedness Plan (EPP) as well as the site specific EPP with their supervisor. This will be completed by 8/16/2024.
-All new BLBHS residential employees will review the Journey Emergency Preparedness Plan (EPP) as well as their site specific EPP during Basecamp Orientation (1st week of employment). An attestation will be loaded into Relias upon completion for verification.
-Training plans will be updated to require all BLBHS residential employees to review the Journey EPP as well as their site specific EPP on a yearly basis in perpetuity, with an attestation for verification.
-This will be an ongoing activity.
Adherence to this plan will be monitored by Director of Residential Services during The Safety Committee meeting on a monthly basis, and verified via Safety Committee minutes and Relias training transcripts.
-Corrective Action will be completed by 01/01/2025.
441.184(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of facility provided documentation and interview, it was determined that the facility failed to conduct an additional exercise of the facility's emergency preparedness plan (EPP). This applied to all individuals at the facility. Findings included:
Review of facility provided emergency preparedness documentation was completed on July 12, 2024. This review revealed that the facility experienced an emergency that required activation of the facility's EPP on January 14, 2024. Further review of facility provided documentation failed to reveal that an additional exercise was completed within the previous 12 months.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:11 AM. The DRS confirmed that no additional exercise was completed for the facility within the previous 12 months.
Plan of Correction:Safety Committee will establish a date for drill or tabletop exercise during the August 2024 meeting. Drill/Tabletop exercise will be completed by September 30, 2024. The agency will plan to conduct at least 2 drills annually for any program that has not experienced and actual event. All actual events will be properly reviewed and debriefed and all documentation will be saved on the network in a central location.
-Safety Committee Meeting agenda will include a standing item as reference to annual completion of 2 drills and/or tabletop exercises for all BLBHS PRTFs.
-This will be an ongoing activity. Adherence to this plan will be monitored by Director of Residential Services during the Safety Committee meeting on a monthly basis, and verified via the Safety Committee meeting minutes with a completed drill or tabletop exercise.
-Corrective Action will be completed by 01/01/2025.
Initial Comments:
A validation survey was conducted July 8-12, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was six and the sample consisted of four individuals.
Plan of Correction:
483.358(a) STANDARD
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that emergency safety interventions (ESI) were only implemented with an order from a physician. This applied to one (#1) of four individuals in the survey sample. Findings included:
A record review for Individual #1 was completed on July 11, 2024. This review revealed that Individual #1 experienced an ESI on February 26, 2024, at 7:35PM, which lasted 31 minutes. A review of this report indicated that staff implemented "Multiple Supine Extension" therapeutic hold. Further review of the physician's order failed to reveal that this ESI was ordered by the physician.
An interview with director of residential services (DRS) was completed on July 12, 2024, at 10:29 AM. The DRS confirmed that Individual #1 experienced an ESI implemented by staff that was not ordered by the physician.
Plan of Correction:Training will occur with all staff on the requirement to only implement holds that are ordered by the practitioner, as well as the continuum of responses in crisis to ensure that the least restrictive alternative is implemented. Training will be completed by 8/2/2024.
Restraint orders and actual holds implemented will be reviewed during daily restraint paperwork review by Program Manager, and Director of Residential Services will be notified if any discrepancies arise regarding implementation of holds, with immediate follow up and action plan implementation for those involved.
-This will be an ongoing process. This process will be reviewed monthly in Crisis Management Committee, and reported quarterly at Performance Improvement Council (PIC). Corrective Action will be monitored by Director of Residential Services and evidenced by Crisis Management Committee/PIC minutes, and congruence between restraint orders and holds implemented.
-Corrective Action will be completed by 01/01/2025.
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 record reviews and interview, it was determined that the facility failed to ensure that face-to-face comprehensive physical assessments occurred within one hour of an emergency safety intervention (ESI). This applied to one (#2) of four individuals in the survey sample. Findings included:
1. A record review for Individual #2 was completed on July 11, 2024. This review revealed that Individual #2 experienced an ESI on the following dates:
- March 13, 2024, at 5:15 PM; which lasted 33 minutes
- May 5, 2024, at 4:55 PM; which lasted 36 minutes
- May 24, 2024, at 11:35 AM; which lasted 47 minutes
A review of nursing assessment documentation for these dates, revealed that the nursing assessments took place over "Zoom" or "via telehealth" with the assistance of facility staff.
An interview was conducted with director of residential services (DRS) on July 12, 2024, at 10:30 AM. The DRS confirmed that face-to-face comprehensive physical assessments did not occur for Individual #2 for the above ESIs. The DRS further confirmed that it was the facility's practice to utilize Zoom following an ESI to complete face-to-face comprehensive physical assessments of individuals if a registered nurse was not in-person at the facility.
Plan of Correction:Clients will continue to be assessed by on call nursing personnel in a face to face manner. In the event that on call nursing personnel are not available for scheduling of face to face assessments, all clients will be transported to a local emergency room/Urgent Care facility in order for completion of face to face assessment.
-All residential nurses and staff will be formally retrained to this change in procedure. Informal training has been completed.
-This will be an ongoing activity. This process will be monitored and reviewed on a weekly basis by the Program Manager and reported quarterly in Performance Improvement Council (PIC). Adherence to this plan will be monitored by Director of Residential Services.
The individuals identified have received multiple in person nursing assessments since the date of the restraint in question with no notable concerns.
-Corrective action will be completed by 01/01/2025.*
*Note: This process was changed during the audit and all assessments have been completed face to face since 7/9/2024.
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 record review and interview, it was determined that the facility failed to ensure that all orders for an emergency safety intervention (ESI) included the specific restraints for which the intervention was permitted by the ordering physician. This applied to two (#1 and #2) of four individuals in the survey sample. Findings included:
1. Record review for Individual #2 was completed on July 11, 2024. This review revealed the following:
Individual #2 experienced an ESI on March 13, 2024, at 5:15 PM. This review revealed an ESI physician's order for an "upper torso seated/kneeling, upper torso seated/kneeling multiple, supine torso assist, and multiple person supine torso" therapeutic holds. This review further revealed that facility staff additionally implemented a "cradle seated/kneeling" therapeutic hold.
Individual #2 experienced an ESI on June 12, 2024, at 6:05 PM. This review revealed an ESI physician's order for an "cradle seated/kneeling, multiple person supine torso" and "multiple supine extension" therapeutic holds. This review further revealed that facility staff additionally implemented an "upper torso assist" therapeutic hold.
2. Record review for individual #1 was completed on July 11, 2024. This review revealed that Individual #1 experienced an ESI on May 15, 2024, at 6:27 PM. This review revealed an ESI physician's order for an "cradle seated/kneeling, multiple person supine torso" and "multiple supine extension" therapeutic holds. This review further revealed that facility staff additionally implemented a "hook/carry transport" therapeutic hold.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:33 AM. The DRS confirmed that the additional therapeutic restraint holds implemented by staff were not included in the order from the physician for Individual #1 and #2.
Plan of Correction:-Training will occur with all nursing staff responsible for obtaining restraint orders from the practitioner to ensure orders are obtained timely and completed accurately. This training will be completed by 8/2/2024.
-Training will occur with all staff to ensure that only holds that are ordered by physician are implemented. This training will be completed by 8/2/2024.
-During daily review of restraint documentation, Program Manager will alert Director of Nursing if an issue exists with the order. Director of Nursing will meet with the respective nurse or alert the practitioner to the issue, to allow for consultation and documentation. Program Manager will alert Director of Residential Services and Director of Nursing if a hold is implemented that wasn't ordered, and will immediately meet with the staff involved to determine the steps necessary to correct.
-This is and ongoing process. This process will be monitored by Director of Residential Services, reported quarterly at Performance Improvement Council, and evidenced by PIC meeting minutes and congruent orders and implementation of holds.
The agency will not retroactively correct the incorrect documentation on this deficiency. The agency will maintain a copy of this plan of correction on file for future reference.
-Corrective Action will be completed by 01/01/2025.
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, it was determined that the facility failed to ensure that a face-to-face discussion was completed with the individual within 24 hours of the emergency safety intervention (ESI). This applied to two (#1 and #2) of four individuals in the survey sample. Findings included:
1. A record review was completed for Individual #1 on July 11, 2024. This review revealed the following:
- Individual #1 experienced an ESI on March 15, 2024, at 7:50 PM. This review revealed that a face-to-face discussion occurred on May 16, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #1 experienced an ESI on April 21, 2024, at 8:21 PM. This review revealed that a face-to-face discussion occurred on April 22, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #1 experienced an ESI on May 14, 2024, at 7:44 PM. This review revealed that a face-to-face discussion occurred on May 15, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #1 experienced an ESI on May 19, 2024, at 6:48 PM. This review revealed that a face-to-face discussion occurred on May 20, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #1 experienced an ESI on May 20, 2024, at 5:47 PM. This review revealed that a face-to-face discussion occurred on May 22, 2024.
2. A record review was completed for Individual #2 on July 11, 2024. This review revealed the following:
- Individual #2 experienced an ESI on March 13, 2024, at 5:15 PM. This review revealed that a face-to-face discussion occurred on March 14, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #2 experienced an ESI on April 21, 2024, at 2:22 PM. This review revealed that a face-to-face discussion occurred on April 22, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #2 experienced an ESI on April 29, 2024, at 5:48 PM. This review revealed that a face-to-face discussion occurred on April 30, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #2 experienced an ESI on May 8, 2024, at 6:24 PM. This review revealed that a face-to-face discussion occurred on May 9, 2024. Further review failed to reveal the time that this discussion took place.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:35 AM. The DRS confirmed that there is no documentation that face-to-face discussions occurred within 24 hours of the ESIs for Individual #1 and #2.
Plan of Correction:-Clients identified missing debrief for a period of 14 days prior to the audit will be given an opportunity, if willing, to complete a client debriefing form. The facility will discuss the lack of completed client and staff debriefing during Crisis Management Committee Meeting (7/31/2024). The Program Manager will review the ESI and ensure that all debriefing forms are present when the ESI is reviewed.
-Training will be provided to all staff to review the regulations and importance of client and staff debriefings. Training will be completed by 8/2/2024.
-This will be an ongoing activity. This process will be reviewed during the Crisis Management Committee on a monthly basis, monitored by Director of Residential Services, and reported quarterly during Performance Improvement Council (PIC). Corrective action will be evidenced by review of Crisis Management/PIC meeting minutes and completed debriefings within 24 hours.
-Corrective Action will be completed by 01/01/2025
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 record reviews and interview, it was determined that the facility failed to ensure that all staff that participated in an emergency safety intervention (ESI) also participated in the post-intervention de-briefing within 24 hours. This applied to two (#1 and #2) of four individuals in the survey sample. Findings included:
1. A record review was completed for Individual #1 on July 11, 2024. This review revealed the following:
- Individual #1 experienced an ESI on March 15, 2024, at 7:50 PM. This review revealed documentation that the staff de-briefing occurred on March 16, 2024. Further review failed to reveal the time that this post-intervention de-briefing took place.
- Individual #1 experienced an ESI on May 14, 2024, at 7:44 PM. This review revealed documentation that one staff that had participated in the ESI completed the post-intervention staff de-briefing on May 18, 2024.
- Individual #1 experienced an ESI on May 19, 2024, at 6:48 PM. This review failed to reveal documentation that one of the staff who had participated in the ESI had also participated in the post-intervention staff de-briefing.
- Individual #1 experienced an ESI on May 20, 2024, at 5:47 PM. This review revealed documentation that two staff that had participated in the ESI completed the post-intervention staff de-briefing on May 22, 2024, and that one staff had not signed that they had completed the post-intervention staff de-briefing.
2. A record review was completed for Individual #2 on July 11, 2024. This review revealed the following:
- Individual #2 experienced an ESI on May 22, 2024, at 5:58 PM. This review failed to reveal that one of the staff who had participated in the ESI had also participated in the post-intervention staff de-briefing.
An interview was conducted with the director of residential services on July 12, 2024 at 10:37 AM. The DRS confirmed that the post-intervention staff de-briefings above for Individuals #1 and #2 either did not occur within 24 hours of the ESI or that the documentation failed to indicate that the post-intervention staff de-briefing occurred within 24 hours of the ESI.
Plan of Correction:-Staff identified missing debrief for a period of 14 days prior to the audit will meet with their supervisor to debrief and document the discussion. The program manager will review the documentation of all ESI's to ensure the debriefing forms are present.
-The facility will discuss the lack of completed client and staff debriefing during Crisis Management Committee Meeting (7/31/2024).
-Training will be provided to all staff to review the regulations and importance of client and staff debriefings, with training to be completed by 8/2/2024.
-This is an ongoing activity. This process will be monitored during the Crisis Management Committee on a monthly basis, monitored by Director of Residential Services, and reported quarterly during Performance Improvement Council (PIC). Corrective action will be evidenced by review of Crisis Management/PIC meeting minutes and completed debriefings within 24 hours.
-Corrective Action will be completed by 01/01/2025.
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 staff training records and interview, it was determined that the facility failed to ensure that all staff were trained and demonstrated competencies in safe crisis management (SCM) on a semi-annual basis. This applied to four of 27 staff training records reviewed. Findings included:
A review of facility provided staff training records for 27 staff was completed on July 11, 2024. This review revealed that four of 27 staff were not trained in SCM on a semi-annual basis.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:18 AM. The DRS confirmed that the four staff had not been trained in SCM on a semi-annual basis.
Plan of Correction:-Staff members out of compliance have since completed SCM training and compliance.
-Supervisors will generate and review a monthly report to determine pending expirations (within 30 days) and past due trainings. Supervisors will provide feedback to staff and assist in scheduling training for those individuals who have pending or past due trainings.
-Any staff member falling out of compliance with semi-annual SCM review training will not participate in any SCM holds, will not be left alone with any clients. A supervision note will be filed to reflect the restriction, as well as the date of the next scheduled training which the employee will attend.
-Training compliance will be reported out during monthly Program Manager group supervision and identified deficiencies will be reviewed during biweekly individual supervision with Program Manager.
-This is an ongoing process. Director of Residential Services will document the results of individual and group supervision in a conference note to include notification of those with pending training deadlines, identified deficiencies, and timelines for correction. Professional Development Specialists and other certified SCM trainers will be consulted and utilized to achieve training compliance as needed.
-This process will be monitored by Director of Residential Services, evidenced by achievement of 100% training compliance as noted in the employee record via Relias transcripts.
-Corrective Action will be completed by 9/1/2024.
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