Initial Comments:
A validation survey was conducted October 26 - 27, 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 October 26 - 27, 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 four individuals.
Plan of Correction:
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 conducted with the resident within 24 hours after the use of a restraint. This applied to one of two restraints reviewed. Findings included:
Record review for Individual #1 was completed on October 26, 2021. This review revealed that Individual #1 had experienced two restraints, one of August 16, 2021, and one on September 3, 2021. This review failed to reveal that a face to face discussion was conducted with Individual #1 following the August 16, 2021, restraint.
Interview with the director of residential services on October 26, 2021, at 1:35 PM, confirmed that there was no face to face discussion conducted with Individual #1 after the restraint on August 16, 2021.
Plan of Correction:In order to correct the listed deficiency, the client noted will have an opportunity, if willing, to complete a client debriefing form. The facility discussed the lack of the completed client debriefing form during the Crisis Management Committee Meeting on 10/27/2021. The committee reviewed the regulation and the importance of completing the debriefing process following all incidents. The facility will complete an all staff training in all PRTF locations to review the regulations and importance of both client and staff debriefings to be completed by 11/15/21. The facility will monitor each and every incident during the medical records review to ensure all debriefings were completed timely. This information will then be monitored monthly during the Crisis Management Committee meeting, as well as quarterly at the Performance Improvement Council Meeting. This corrective action will be monitored by the Director of Residential Services.
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