Initial Comments:
A validation survey was conducted July 10-13, 2023, 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 11 and the sample consisted of six residents. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted July 10-13, 2023, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was 11 and the sample consisted of six residents.
Plan of Correction:
483.358(d) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse, while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must verify the verbal order in a signed written form in the resident's record. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all verbal orders for emergency safety interventions were verified and signed by the licensed practitioner. This applied to two (#3 and #4) of six individuals in the survey sample. Findings included:
1. Record reviews were completed for Individuals #3 and #4 on July 12, 2023. This review revealed that Individual #3 was restrained on March 6, 2023, March 11, 2023, March 13, 2023, and May 12, 2023. This review also revealed that Individual #4 was restrained on February 4, 2023, and May 31, 2023. These reviews failed to reveal that the verbal orders for the above restraints were verified and signed by the ordering practitioner.
Interview with the compliance officer (CO) on July 13, 2023, at 8:55 AM, confirmed that the verbal orders for the above dated restraints for Individuals #3 and #4 had not been signed by the ordering licensed practitioner.
2. Record review was completed for Individual #3 on July 12, 2023. This review revealed that Individual #3 was restrained on May 5, 2023. This review failed to reveal that the verbal order was signed and verified by the ordering practitioner until July 12, 2023.
Interview with the CO on July 13, 2023, at 9:22 AM, confirmed that the order for the above restraint had not been signed by the ordering licensed practitioner in a timely manner. Further, the CO stated that it is the expectation of the facility that the verbal orders are verified by the ordering practitioner as soon as possible, according to the work schedule.
Plan of Correction:Revised Plan of Correction Added 8/11/23
The Director of Nursing has reviewed the physician orders for the identified individuals and the nurses involved to correct the deficiency. The director immediately printed the electronic Therapeutic Hold Orders that were deficient for the identified individuals and met with the ordering provider, a PMHNP, for physical signatures, as the EMR form is not equipped for two signatures.
The facility will act to protect other individuals by conducting retraining of all medical staff on proper policy and procedure: When nursing has been notified of an Emergency Physical Safety Intervention in process, the nurse immediately notifies the treatment team physician to obtain the hold order and for consultation throughout the period of the ESPI. Training was done on 7/13/23 with all nursing staff and medical providers. Moving forward, this updated process ensures that the attending physician or covering physician will receive all calls and provide orders for all hold orders. The previous process of utilizing the CRNP was changed on 7/13/2023. Systemic compliance with the new procedure began on 7/14/2023. First re-evaluation of process is scheduled 8/16/2023.
The Director of Nursing, along with the assist Direct of Residential will review all Therapeutic Hold Orders every Wednesday morning prior to Incident Review meeting and randomly to ensure appropriate compliance; we expect to have full compliance with the corrective action procedures by September 13, 2023.
483.360 STANDARD
CONSULTATION WITH TREATMENT TEAM PHYSICIAN
Name - Component - 00
If a physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion orders the use of restraint or seclusion, that person must contact the resident's treatment team physician, unless the ordering physician is in fact the resident's treatment team physician. The person ordering the use of restraint or seclusion must-
(a) Consult with the resident's treatment team physician as soon as possible and inform the team physician of the emergency safety situation that required the resident to be restrained or placed in seclusion; and
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that for all restraints ordered by a licensed practitioner, the practitioner directly contacted the resident's treatment team physician for notification of the restraints. This applied to two (#3 and #4) of six individuals in the survey sample. Findings included:
Record reviews was completed for Individuals #3 and #4 on July 12, 2023. These reviews revealed that the individuals experienced restraints, ordered by a licensed practitioner other than their treatment team physician, on the following dates:
Individual #4 - February 4, 2023
Individual #3 - March 6, 2023
Individual #3 - March 11, 2023
Individual #3 - March 13, 2023
Individual #3 - May 12, 2023
Individual #4 - May 31, 2023
Record reviews of these individuals failed to reveal that the individuals' treatment team physician was contacted by the ordering practitioner.
Interview with the compliance officer on July 13, 2023, at 8:57 AM confirmed that there was no documentation that the ordering practitioner notified the treatment team physician on the above six restraint dates for these two individuals.
Plan of Correction:
Revised Plan of Correction Added 8/11/23
The Director of Nursing has reviewed the physician orders for the identified individuals and the nurses involved to correct the deficiency. The director immediately printed the electronic Therapeutic Hold Orders that were deficient for the identified individuals and met with the ordering provider, a PMHNP, for physical signatures, as the EMR form is not equipped for two signatures.
The facility will act to protect other individuals by conducting retraining of all medical staff on proper policy and procedure: When nursing has been notified of an Emergency Physical Safety Intervention in process, the nurse immediately notifies the treatment team physician to obtain the hold order and for consultation throughout the period of the ESPI. Training was done on 7/13/23 with all nursing staff and medical providers. Moving forward, this updated process ensures that the attending physician or covering physician will receive all calls and provide orders for all hold orders. The previous process of utilizing the CRNP was changed on 7/13/2023. Systemic compliance with the new procedure began on 7/14/2023. First re-evaluation of process is scheduled 8/16/2023
The Director of Nursing, along with the assist Direct of Residential will review all Therapeutic Hold Orders every Wednesday morning prior to Incident Review meeting and randomly to ensure appropriate compliance; we expect to have full compliance with the corrective action procedures by September 13, 2023.
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 record review, facility provided staff training records, and interview, it was determined that the facility failed to ensure that all staff demonstrated competencies in safe crisis management (SCM) on a semiannual basis. This applied to all the residents at the facility. Findings included:
1. A review of facility provided staff training records was completed on July 11, 2023. This review revealed the following SCM training dates:
Staff A: April 14, 2022, December 28, 2022, and June 29, 2023.
Staff B: August 30, 2022, and May 25, 2023.
Staff C: July 14, 2022, and May 26, 2023.
Interview with the compliance officer (CO) was completed on July 13, 2023, at 8:46 AM. At this time, the CO confirmed that three staff were not trained on a semiannual basis in safe crisis management.
2. Record review for Individual #3 was completed on July 12, 2023. This review revealed that Individual #3 was restrained by staff B and staff C on May 12, 2023. Further, Individual #3 was restrained by staff C on March 11, 2023.
Interview with the CO was completed on July 13, 2023, at 9:26 AM. The CO confirmed that at the time of the above restraints, staff B and C were not in compliance with SCM semiannual training.
Plan of Correction:Plan of Correction Added 8/9/23
The individuals identified in the deficiency statements were met with and trained in safe crisis management (SCM) to ensure compliance. The Assistant Directors met with all unit management teams on 07/19/23 and 7/26/23 discussing Policy and Procedures for staff SCM training expectations and requirements. Assistant Directors will continue to meet with Unit Management on a quarterly basis and discuss Policy and procedures for training requirements.
The unit management team will track and receive notices from our Relias training system when their staff are due for SCM training. Unit management will schedule their staff SCM training courses to ensure they adhere to the semiannual criteria.
The Unit management team, SCM instructors, and Assistant Residential Directors will receive Agency staff SCM recertification due dates to ensure compliance. SCM due dates will be reviewed monthly by SCM instructors and Assistant Directors.
SCM instructors will schedule each unit SCM training on a quarterly basis to keep all staff in compliance. SCM instructors will also schedule SCM training to meet the specific needs of each unit.
To ensure that unit management are scheduling SCM training for their staff the Assistant Residential Directors will monitor compliance.
The Assistant Residential Director (one of two specific staff personnel) will be responsible for monitoring the corrective actions.
These corrective action steps are in place as of 7/26/23 and will continue to be monitored monthly. Assistant Directors will meet with the management team quarterly (beginning on 10/18/23 and ongoing thereafter) to discuss SCM training requirement compliance to monitor and rectify the identified deficiencies.
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