Initial Comments:
A validation survey was conducted September 1-3, 2015, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. At the time of the survey the census was 13, and the sample consisted of six individuals.
Plan of Correction:
483.356(d) ELEMENT
PROTECTION OF RESIDENTS
Name - Component - 00
Contact information. The facility's policy must provide contact information, including the phone number and mailing address, for the appropriate State Protection and Advocacy organization.
Observations:
Based on record review and interview it was determined that the facility failed to ensure that contact information for the State Protection and Advocacy organization was provided to every individual, or their guardian, upon admission. This applied to all 13 individuals at the facility. Finding included:
Record reviews were completed for all six individuals in the survey sample from September 1-3, 2015. These reviews failed to reveal documentation the State Protection and Advocacy organization contact information was provided upon admission.
Interview with the quality and compliance specialist on September 1, 2015, at 12:00 PM confirmed that the sample individual's records do not contain documention that the State Protection and Advocacy contact information was provided. The quality and compliance specialist further stated it is not the current practice of the facility to provide the complete contact information to individuals upon admission.
Plan of Correction:Abraxas I will ensure all residents and their parent/legal guardian will receive the complete contact information (phone number and mailing address) upon the resident?s admission to the program. All current residents and their parent/legal guardian will also be provided with the complete contact information for the Disability Rights Network by September 18, 2015.
The facility Intake Policy was revised on September 14, 2015, to include the complete contact information for the Disability Rights Network. All current residents and their parent/legal guardian will receive, in writing, the contact information for the Disability Rights Network by September 18, 2015. Residents will sign an acknowledgement form confirming their receipt of this information and this will be filed in the resident?s chart. All parents/legal guardians will be asked to return a signed acknowledgement confirming their receipt of the information. If/when these are returned, they will also be filed in the resident?s chart.
The client handbook was revised on September 14, 2015, to include the complete contact information for the Disability Rights Network. Effective September 14, 2015, all new intakes will receive the Disability Rights Network contact information within the client handbook during the intake process which occurs immediately upon admission. Residents will sign an acknowledgement form confirming their receipt of this information and this will be filed in the resident?s chart. Also effective September 14, 2015, the revised version of the client handbook will be included in the family welcome packet sent to all parents/legal guardians of new intakes. All parents/legal guardians will be asked to return a signed acknowledgement confirming their receipt of the information. If/when these are returned, they will also be filed in the resident?s chart.
The Program Manager will audit all current resident charts on September 21, 2015 to verify they have each received the complete contact information for the Disability Rights Network. Moving forward, all resident charts will be audited by a Treatment Supervisor within one week of a resident?s admission to the program to verify the resident has received the complete contact information for the Disability Rights Network.
On a monthly basis, each resident chart will be audited by a Treatment Supervisor. All audit tools will be submitted to the Program Manager who will then select a sample of resident charts to audit to verify all residents have received the complete contact information for the Disability Rights Network. All audit tools will be maintained by the Program Manager. The Program Manager will also formally report the results of these audits to the Leadership Team once a month for the next three months. If there is 100% compliance during those three months, reporting during Leadership Meetings will occur once every six months.
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 an emergency safety intervention (ESI) ordered by the physician specified the type of restraint permitted to be implemented for one (#4) of four individuals in the survey sample who experienced restraints. Findings included:
A record review for Individual #4 was completed on September 2, 2015. This review revealed that on May 20, 2015 at 11:10 AM Individual #4 experienced a restraint. A review of the verbal order for the restraint failed to indicate the specific holds ordered by the practitioner.
An interview with the facility nurse who took the order was completed on September 2, 2015, at 9:45 AM. The facility nurse confirmed that the specific restraint was not included in the verbal order for Individual #4's restraint.
Plan of Correction:Abraxas I will ensure all restraint orders include the specified type of restraint permitted to be implemented for a resident experiencing a restraint.
On September 9, 2015, the Program Manager and Quality & Compliance Specialist met with the Nurse Manager to review individual #4?s restraint order from May 19, 2015. The Nurse Manager was informed that all restraint orders must include the permitted restraints authorized by the physician to be utilized during the restraint.
Moving forward, the nurse who receives the restraint order from the physician will review the order to verify the authorized restraints from the physician are properly documented on the restraint order.
Beginning the week of September 14, 2015, the Program Manager will review all restraint orders on a weekly basis. If deficiencies are found in a restraint order, the Program Manager will meet with the nurse who received the restraint order and document the meeting in a supervisory conference note. Every supervisory conference note will be forwarded to the Nurse Manager and Facility Director.
Beginning October 1, 2015, the Quality & Compliance Specialist will review all restraint orders on a monthly basis to confirm the findings of the Program Manager?s review are accurate. The Program Manager and Quality & Compliance Specialist will formally report the results of these reviews to the Leadership Team once a month for the next three months. If there is 100% compliance during those three months, reporting during Leadership Meetings will occur once every six months.
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 restraint ordering practioner notified the treatment team physician of the individuals restraint. This applied to all four individuals (#2, #3, #4, #5) in the survey sample of six that had experienced restraints. Findings included:
Record reviews were completed for all six individuals in the survey sample from September 1-3, 2015. This review revealed that 4 of the 6 individuals in the survey sample had experienced restraints while at the facility. These reviews failed to reveal documentation that the ordering practioner notified the treatment team physician for 10 of 15 combined restraints for Individuals #2, #3, #4, and #5.
Interview with the facility nurse on September 1, 2015, at 12:35 PM, confirmed that the above individual's records do not contain documention that the ordering practioner notified the treatment team physician of those 10 restraints . The facility nurse further stated it is not the practice of the facility's current contracted practioner to send this notification.
Plan of Correction:Abraxas I will ensure there is communication from the on call psychiatrist to the treatment team psychiatrist anytime a restraint order is initiated.
As discussed during the on-site Department of Health audit, the on call psychiatrist has not been agreeable to communicating with the treatment team psychiatrist directly; rather, the Nurse Manager has been managing contact between the two psychiatrists. Therefore, on September 8, 2015, the Nurse Manager once again informed the on call psychiatrist of the requirement to communicate and consult with the treatment team psychiatrist and explained how we were cited during a recent Department of Health audit due to individuals #2, #3, #4 and #5 restraints not being properly communicated to the treatment team psychiatrist. Although the current on call psychiatrist remains reluctant about doing so, he has agreed that he will directly communicate any physical interventions with the treatment team psychiatrist that occur between now and the termination of his working agreement with Abraxas I.
Since the current on call psychiatrist has been resistant to direct communication and consultation with the treatment team psychiatrist, the Abraxas I Facility Director has initiated the process of retaining a new on call psychiatrist who is amicable to doing so. Once a new on call psychiatrist is attained, the Facility Director will terminate the working agreement with the current on call psychiatrist.
Once the new on call psychiatrist is on staff, the Nurse Manager and Program Manager will meet with him or her to review this standard and the facility?s expectations regarding direct communication between the two psychiatrists.
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 the facility failed to ensure that post intervention debriefings for residents were completed within 24 hours and included an opportunity for discussion with the resident regarding the physical restraint. This applied to one of four individuals in the sample who experienced restraints. Findings included:
Record review for Individual #4 was completed on September 2, 2015. This review revealed that on May 19, 2015, Individual #4 experienced a restraint. Further review revealed that the debriefing regarding this restraint with Individual #4 did not occur until May 22, 2015.
Interview with the quality and compliance specialist on September 2, 2014, at 12:10 PM, confirmed that the debriefing with Individual #4 was completed beyond the required 24 hour time frame.
Plan of Correction:Within 24 hours after the use of a restraint, a team member will complete a debrief/review (Life Space Interview) with each resident who experiences a restraint.
A Treatment Supervisor will verify that a Life Space Interview is completed or there are documented attempts to complete the Life Space Interview within 24 hours with any resident involved in a restraint. Individual #4?s restraint documentation was reviewed with the Treatment Supervisor responsible and a supervisory conference note was completed.
Since the Treatment Supervisors are responsible for verifying that the Life Space Interview is completed within 24 hours with any resident who is involved in a restraint, the Program Manager will meet with all of the Treatment Supervisor II level personnel and retrain them on the process for completing and documenting the review/debrief sessions. On October 1, 2015, the Program Manager will meet with all Treatment Supervisors during the scheduled monthly meeting to review and retrain them on the process for completing and documenting the review/debrief sessions.
Each week, the Program Manager will review the documentation from each restraint to verify all required documentation is completed correctly and placed in the respective resident?s chart. Immediate issues with the documentation will be reviewed with the Treatment Supervisor responsible for ensuring the Life Space Interview is conducted properly.
The Program Manager will report his findings on a monthly basis at the Leadership Meeting. Appropriate corrective actions will be developed and implemented when necessary.
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