Initial Comments:
A recertification survey visit was conducted on August 4-5, 2021. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
The UHS of Doylestown LLC Resiliency facility 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 4-5, 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 ten and the sample consisted of six residents.
Plan of Correction:
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 review of resident records and interview with the administrative staff, the facility failed to report serious occurances involving a resident to both the State Medicaid agency and the state designated protection and advocacy system for one of one sample Individual reviewed, who experienced a serious occurrence as documented by the facility. This practice is specific to Resident #4.
Findings include:
A review of resident records and facility's incident reports, for the time period of February 2021 until the date of this survey, was completed on 08/04/2021 between 9:00 AM and 12:00 AM and again on 08/05/2021 between 8:30 AM and 9:30 AM. This review revealed the following;
Resident #4;
On 07/08/2021 at 8:30 AM, Resident #4 was placed in a manual hold due to imminent risk (8:34 AM - 8:40 AM). While being placed in the hold, staff lost footing and fell on Resident#4's arm. He was assessed by nursing and the medical practitioner who sent him to the local emergency department. Resident #4 was assessed in the emergency department where a fracture to the left arm was noted. Continued review of Resident #4's record revealed that there was no evidence that either the State Medicaid agency or the state designated Protection and advocacy system - Disability Rights Network - was notified of the serious occurrence.
Interview with the Director of Compliance and Physician Relations completed on 08/05/2021 at approximately 09:00 AM, confirmed that the facility did not notify the
above agencies at the time of the serious occurrence.
Plan of Correction:A report was filed for Resident #4 on 8/4/2021 through The Home and Community Services Information System (HCSIS) which was provided as evidence during the course of the survey on 8/5/2021. HCSIS reports satisfy the requirement for State Medicaid agency reporting.
The Office of Children Youth and Families (OCYF) was notified immediately following and within 24 hours of the event as required. Documentation of this notification, dated 7/8/2021 10:10am, was provided as evidence during the course of the survey on 8/5/2021 regarding Resident #4.
Foundations continues to follow the Office of Medical Assistance Program Bulletin # 53-03-01 which informs providers that the Office of Children Youth and Families (OCYF, licensing agency) will notify Pennsylvania Protection and Advocacy (Disability Rights Network) of the serious occurrence to avoid duplicative facility reporting.
In order to assure ongoing compliance with the standard, the Director of Compliance met with members of the leadership and compliance teams on 8/5/2021 to review and facilitate comprehensive understanding of Federal and State reporting criteria and timeliness as required. All serious occurrences will continue to be reviewed daily by the Director of Compliance or designee.
On 8/5/2021, a review of facility policy, procedure and all serious occurrences was conducted to ensure reporting for identified events as required. In order to assure ongoing compliance with the standard, the Director of Compliance met with members of the leadership and compliance teams on 8/5/2021 to review and facilitate comprehensive understanding of Federal and State reporting criteria and timeliness as required. All serious occurrences will continue to be reviewed daily by the Director of Compliance or designee. All serious occurrences will be reported monthly to the Performance Improvement Committee and Medical Executive Committee and Quarterly in Board of Governors.
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