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 nine. 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 nine and the sample consisted of six residents.
Plan of Correction:
441.154 ELEMENT
ACTIVE TREATMENT
Name - Component - 00
Active treatment.
Inpatient psychiatric services must involve "active treatment", which means implementation of a professionally developed and supervised individual plan of care, described in §441.155 that is-
(a) Developed and implemented no later than 14 days after admission; and
(b) Designed to achieve the beneficiary's discharge from in patient status at the earliest possible time.
Observations:
Based on record review and interview, it was determined that the facility failed to implement an active treatment plan within 14 days of admission. This applied to two (#2 and #6) of six individuals in the survey sample. Findings included:
Record reviews were completed for Individuals #2 and #6 on July 13, 2023. The record review for Individual #2 revealed an admission date of July 29, 2021, and the initial treatment plan was implemented on August 19, 2021. The record review for Individual #6 revealed an admission date of February 2, 2023, and the initial treatment plan was implemented on February 22, 2023.
Interview with the compliance officer on July 13, 2023, at 8:50 AM, confirmed that the initial treatment plans for Individual #2 and Individual #6 were not implemented within 14 days of their admissions.
Plan of Correction:Plan of Correction Added 8/9/23
1. Clinical Director was made aware of the issue and addressed the two therapists responsible for the out of compliance initial treatment plans via telephone and email. In doing so, the requirement for plans to be completed within 14 days was restated. Both therapists have weekly consultation with Clinical Director, and new admissions will be discussed during this weekly meeting, including ITP development.
2. HYS recognizes that all clinical therapists have the potential for missing a due date on an initial ITP. Because of this, Clinical Director and Resource Management Team Leader updated the procedures for initial ITP development, as explained in #3. Clinical Director and Compliance Officer will review files the first week of November 2023 to verify all new admissions in the time period of 7/12/2023 through 11/1/2023 had initial ITPs submitted within 14 days of admission. Clinical Director will notify therapists via email for any records found to be deficient in meeting the 14-day initial ITP goal, and therapists will receive supervision to include procedure review and how to build an appropriate treatment plan.
3. Clinical Director announced a new procedure via memo on 7/12/23. The new procedure dictates that therapists will complete a draft of the initial ITP for the date of the initial team meeting. The plan will be finalized after the collaborative team meeting, and the resource manager assigned to the case will be responsible to make sure the ITP is finalized and submitted into the client record the day of the initial meeting.
4. Resource Management Team Leader will notify Clinical Director of any plans found to be deficient in meeting the 14-day requirement, and this notification will take place immediately via email. HYS has an independent contractor who completes quarterly file reviews. This reviewer will now look for initial ITP compliance in addition to the typical items assessed. Reviewer will notify Clinical Director if ITPs are found to be out of compliance with 14-day requirement. Therapists displaying this deficient practice will receive a supervision meeting within a week of Clinical Director's receipt of reviewer's notification or Resource Management Team Leader's notification. Supervision will include procedure review and examination of appropriate ITP development. This supervision will be documented on the monthly clinical supervision log.
5. Clinical Director, Resource Management Team Leader, and Compliance Officer will monitor the corrective actions. Resource Management Team Leader and resource managers will verify initial ITPs are submitted in the electronic health record on the day of the initial meeting starting immediately. Clinical Director and Compliance Officer will monitor the ongoing implementation of the corrective action by completing a review of files the first week of November 2023 to verify all new admissions in the time period of 7/12/23 through 11/1/23 had initial ITPs submitted within 14 days of admission. Independent Contractor will complete quarterly reviews on an ongoing basis.
6. Procedural change was implemented on 7/12/23. Clinical Director and Compliance Officer will complete file review week of 11/1/23 to verify ongoing implementation. Independent Contractor will complete next file review at the end of the current quarter.
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 one (#1) of six individuals in the survey sample. Findings included:
1. Record review was completed for Individual #1 on July 12, 2023. This review revealed that Individual #1 was restrained on March 8, 2023. This review failed to reveal that the verbal order for the above restraint was 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 order for the above restraint for Individual #1 had not been signed by the ordering licensed practitioner.
2. Record review was completed for Individual #1 on July 12, 2023. This review revealed that Individual #1 was restrained on February 7, 2023, at 9:58 PM, and on February 7, 2023, at 10:20 PM. This review further revealed that the verbal orders were not signed and verified by the ordering practitioner until April 21, 2023.
Interview with the CO on July 13, 2023, at 9:22 AM, confirmed that the orders for the above restraints for Individual #1 had not been signed by the 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 review 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 one (#1) of six individuals in the survey sample. Findings included:
A record review was completed for Individual #1 on July 12, 2023. This record review revealed that Individual #1 experienced a restraint, ordered by a licensed practitioner other than their treatment team physician, on March 8, 2023. This review failed to reveal that Individual #1's treatment team physician was contacted by the ordering licensed practitioner for this restraint.
An interviewed with the compliance officer on July 13, 2023, at 8:57AM, confirmed that there was no documentation that the ordering practitioner directly notified the treatment team physician for the above restraint that occurred on March 8, 2023.
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.
483.370(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 review and interview, it was determined that the facility failed to ensure that a face-to-face debriefing with the resident occurred within 24 hours of a restraint. This applied to one (#1) of six individuals in the survey sample. Findings included:
A record review for Individual #1 was completed on July 12, 2023. This review revealed that Individual #1 experienced a restraint on March 8, 2023. This review failed to reveal that a face-to-face debriefing was completed following this restraint.
An interview with the compliance officer was completed July 13, 2023, at 8:56 AM. At this time, it was confirmed that Individual #1 experienced a restraint on March 8, 2023, and there was no documentation of a face-to-face debriefing meeting with Individual #1.
Plan of Correction:Plan of Correction Added 8/9/23
The individual identified in the deficiency statement was met on July 12,2023 and a client debriefing was documented. The Assistant Directors met with all unit management teams on 07/19/23 and 7/26/23 depicting procedures and expectations for completing all client debriefings. Assistant Directors will continue to meet with Unit Management on a quarterly basis and discuss Policy and Procedures for client debriefings.
The unit management team will sign off to ensure their client debriefings are completed as required.
To ensure that Unit management are meeting with clients after each ESPI (restraint) the unit management team will call and send Assistant Residential Directors an email (checklist) listing things completed that day.
The completed client Debriefing form will be routed and reviewed by the Assistant Residential Directors to ensure all follow-up steps are completed.
Client debriefings will be monitored the day of an ESPI (restraint) by the management team and Assistant Directors. Assistant Directors will monitor until documented as completed within 24 hours. Client debriefings will also be monitored for completion during our weekly scheduled Incident Review meetings.
The Assistant Residential Director (one of two specific staff personnel) will be responsible for monitoring the corrective actions.
These corrective action steps started on 7/19/23 and Assistant Directors will review Policy and Procedures of client debriefing with unit management team on a quarterly basis (beginning 10/18/23 and ongoing thereafter) to monitor and rectify the identified deficiencies.
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 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 (#1) of six individuals in the survey sample. Findings included:
A record review for Individual #1 was completed on July 12, 2023. This review revealed that Individual #1 was restrained on March 8, 2023, for three minutes. This review failed to reveal that either of the two staff involved in the restraint for Individual #1 participated in a debriefing following the restraint.
An interview was completed with the compliance officer (CO) on July 13, 2023, at 12:15 PM. The CO confirmed that there was no documentation that either staff participated in a debriefing session following the above restraint for Individual #1.
Plan of Correction:Plan of Correction added 8/9/23
The individual identified in the deficiency statement was met with on July 12,2023 and a staff debriefing was documented. The Assistant Directors met with all unit management teams on 07/19/23 and 7/26/23 depicting procedures and expectations for completing all staff debriefings. Assistant Directors will continue to meet with Unit Management on a quarterly basis and discuss Policy and procedures for staff debriefings.
The unit management team will sign off to ensure their staff debriefings are completed as required.
To ensure that Unit management are meeting with staff after each ESPI (restraint) the unit management team will call and send Assistant Residential Directors an email (checklist) listing things completed that day.
The completed Staff Debriefing form will be routed and reviewed by the Assistant Residential Directors to ensure all follow-up steps are completed.
Staff debriefings will be monitored the day of an ESPI (restraint) by the management team and Assistant Directors. Assistant Directors will monitor until documented as completed within 24 hours. Staff debriefings will also be monitored for completion during our weekly scheduled Incident Review meetings.
The Assistant Residential Director (one of two specific staff personnel) will be responsible for monitoring the corrective actions.
These corrective action steps started on 7/19/23 and Assistant Directors will review Policy and Procedures for staff debriefing with unit management team on a quarterly basis (beginning on 10/18/23 and ongoing thereafter) to monitor and rectify the identified deficiencies.
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 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:
A review of facility provided staff training records was completed on July 11, 2023, revealed the following SCM training dates:
Staff A: August 20, 2022, and May 26, 2023
Staff B: Last completed December 1, 2022
Staff C: February 14, 2022, and December 11, 2022
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 SCM.
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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