Initial Comments:
A validation survey was conducted February 10-13, 2025, 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 four and the sample consisted of four individuals. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted February 10-13, 2025, to determine compliance with the requirements of the 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was four and the sample consisted of four individuals.
Plan of Correction:
483.358(a) STANDARD
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that all emergency safety interventions were ordered by a physician. This applied to two (#1 and #3) of four individuals in the survey sample. Findings included:
Record review for Individual #1 was completed on February 12, 2025. This review revealed that Individual #1 experienced a 13 minute emergency safety intervention on September 18, 2024, at 3:52 PM. This review failed to reveal that there was a physician's order for this restraint.
Record review for Individual #3 was completed on February 12, 2025. This review revealed that Individual #3 experienced a 21 minute emergency safety intervention on September 19, 2025, at 3:50 PM. This review revealed that the physician's order for this restraint was for five minutes.
Interview with associate chief executive officer (ACEO) on February 13, 2025, at 9:00 AM, confirmed that there was no order documented for Individual #1's restraint on September 18, 2024. The ACEO also confirmed that the order for Individual #3 on September 19, 2024, was for five minutes, and the restraint lasted 21 minutes.
Plan of Correction:POC 1 - Obs. #0140
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o The Directors of Nursing (DON) and Clinical Services (DCS) shall receive training with the regulation via review and follow-up with the Chief Executive Officer (CEO), relative to emergency safety intervention authorization. This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The DON and the DCS will require their staff to review all clients for the past three months. In their review they will identify any similar errors and conclude whether a pattern exists within the facility, or systemically.
o A summary report shall be forwarded to the Director of Compliance (DOC) by April 1st, 2025.
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Two corrective measures will be taken
A review of the restraint Policy, which shall be signed off by the DON, DCS, and Program Supervisors (PS).
- A training was held with PS on 2-20-25.
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not re-occur.
o The DON and DCS will work as a team to randomly review 25% of restraints per month to validate the correct application of the regulatory requirements. They will collectively provide a Monthly, April 2025 – June 2025, summary report to the DOC, who shall update the CEO and Associate Chief Executive Officer in July 2025 to review this process.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
483.358(f) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-
(1) The resident's physical and psychological status;
(2) The resident's behavior;
(3) The appropriateness of the intervention measures; and
(4) Any complications resulting from the intervention.
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that all face-to-face assessments occurred within one hour of initiation of an emergency safety intervention (ESI). This applied to three (#1, #2, and #3) of four individuals in the survey sample. Findings included:
1. Record review was completed for Individual #1 on February 12, 2025. This review revealed that Individual #1 experienced an ESI on September 20, 2024, at 5:08 PM. This review also revealed that the face-to-face assessment for this ESI was completed the same day at 6:35 PM.
2. Record review was completed for Individual #2 on February 12, 2025. This review revealed that Individual #2 experienced an ESI on September 21, 2024, at 6:53 PM. This review also revealed that the face-to-face assessment for this ESI was completed the same day at 8:14 PM.
3. Record review was completed for Individual #3 on February 12, 2025. This review revealed that Individual #3 experienced an ESI on November 17, 2024, at 2:54 PM. This review also revealed that the face-to-face assessment for this ESI was completed the same day at 4:12 PM.
An interview was conducted with the associate chief executive officer (ACEO) on February 13, 2025, at 9:00 AM. During this interview, the ACEO confirmed that the face-to-face assessments were not completed within an hour of initiation for the above ESIs for Individuals #1, #2, and #3.
Plan of Correction:POC 2 - Obs. #0145
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o The Director of Nursing (DON) shall receive training with the regulation via review and follow-up with the Associate Chief Executive Officer (ACEO), relative to face-to-face review within an hour. This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
Requirement: the DON shall bring to this meeting the rationale as to why the timeframe was not met, what barriers were experienced, and possible mitigating action responses. This shall be a focal point for discussion.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The DON will require the Nursing staff to review all clients for the past three months. In their review they will identify any similar errors and conclude whether a pattern exists within the facility, or systemically.
o The DON and their team will identify strategies to mitigate this issue.
o A summary report shall be forwarded to the Director of Compliance (DOC) by April 1st, 2025.
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Two corrective measures will be taken
A review of the restraint Policy, which shall be signed off by the DON, DCS, and Program Supervisors (PS).
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
o The DON and DCS will work as a team to randomly review 25% of holds per month to validate the correct application of the face-to-face regulatory requirements. They will collectively provide a Monthly, April 2025 – June 2025, summary report to the DOC, who shall update the ACEO and Chief Executive Officer in July 2025 to review this process.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
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 all emergency safety interventions ordered by a physician, included the specific restraints and length of time permitted. This applied to one (#2) of four individuals in the survey sample. Findings included:
Record review for Individual #2 was completed on February 12, 2025. This review revealed that Individual #2 experienced emergency safety interventions on September 20, 2024, at 5:50 PM and December 26, 2024, at 10:03 PM. This review failed to reveal that the physician's order for the restraint on September 20, 2024, included the length of time permitted. This review further failed to reveal that the physician's order for the restraint on December 26, 2024, included the length of time and specific interventions permitted.
Interview with associate chief executive officer (ACEO) on February 13, 2025, at 9:00 AM, confirmed that the above order for Individual #2's restraint on September 20, 2024, failed to include a length of time permitted. The ACEO also confirmed that the order for Individual #2 on December 26, 2024, failed to include the length of time and specific interventions permitted.
Plan of Correction:POC 3 - Obs. #0148
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o The Directors of Nursing (DON) shall receive training with the regulation via review and follow-up with the Associate Chief Executive Officer (ACEO), related to documenting time duration and specific holds authorized by the physician. This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
Requirement: the DON shall bring to this meeting the rationale as to why the authorizations were an issue, what barriers were experienced, and possible mitigating action responses. This shall be a focal point for discussion.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The DON will require the Nursing staff to review all clients for the past three months. In their review they will identify any similar errors and conclude whether a pattern exists within the facility, or systemically.
o The DON and their team will identify strategies to mitigate this issue.
o A summary report shall be forwarded to the Director of Compliance (DOC) by April 1st, 2025.
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Three corrective measures will be taken
A review of the restraint policy, which shall be signed off by the DON, DCS, and Facility Supervisors.
Training the DON, Nursing Staff, and Program Supervisors on accurate application and documentation for this requirement.
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
o The DON and DCS will work as a team to randomly review 25% of holds per month to validate the correct application of the face-to-face regulatory requirements. The DOC shall provide training to staff as warranted. They will collectively provide a Monthly, April 2025 – June 2025, summary report to the DOC, who shall update the Chief Executive Officer and ACEO in July 2025 to review this process.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
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 discussion was completed with all individuals within 24 hours of an emergency safety intervention (ESI). This applied to one (#3) of four individuals in the survey sample. Findings included:
A record review was completed for Individual #3 on February 12, 2024. This review revealed that Individual #3 experienced ESIs on January 4, 2025, at 8:40 PM and on January 6, 2025, at 5:49 PM. This review failed to reveal that a face-to-face discussion occurred with Individual #3 following either above ESI.
An interview was conducted with the associate chief executive officer (ACEO) on February 13, 2025, at 9:00 AM. During this interview, the ACEO confirmed that there was no documentation that a face-to-face discussion occurred within 24 hours of the above ESIs for Individual #3.
Plan of Correction:POC 4 - Obs. #0188
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o The Associate Chief Executive Officer (ACEO), Directors of Nursing (DON), and Director of Clinical Services (DCS) shall receive training with the regulation via review and follow-up with the Chief Executive Officer (CEO), relative face-to-face discussion was completed with all individuals within 24 hours of an emergency safety intervention (ESI). This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
Requirement: the ACEO, DON, and DCS shall bring to this meeting the rationale as to why the timeframe was not met, what barriers were experienced, and possible mitigating responses. This shall be a focal point for discussion.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The ACEO, DON, and DCS will require their supervisory staff to review to ensure that the debrief is facilitated in a timely manner aligned to the regulation.
o The ACEO, DON and DCS will identify strategies to mitigate this issue.
o A summary report shall be forwarded to the Director of Compliance (DOC) by April 1st, 2025, who will review with the Chief Executive Officer (CEO).
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Three corrective measures will be taken
A review of the restraint Policy, which shall be signed off by the DON, DCS, and Program Supervisors.
Update to the Electronic Health Records to record more accurately in the documentation relative to this POC.
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
o The ACEO, DON, and DCS will work as a team to randomly review 25% of holds per month to validate the correct application of the 24hr. debriefing regulatory requirements. They will collectively provide a Monthly, April 2025 – June 2025, summary report to the DOC, who shall update the Chief Executive Officer in July 2025 to review this process.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
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 reviews and interview, it was determined that the facility failed to ensure that all staff that participated in an emergency safety intervention (ESI) also participated in the post-intervention debriefing within 24 hours. This applied to two (#2 and #3) of four individuals in the survey sample. Findings included:
1. A record review was completed for Individual #2 on February 12, 2025. This review revealed that Individual #2 experienced ESIs on the following dates:
-September 17, 2024, at 6:05 PM
-November 13, 2024, at 11:25 PM
-December 26, 2024, at 10:03 PM
-December 26, 2024, at 10:08 PM
-December 26, 2024, at 10:33 PM
This review failed to reveal documentation that all staff who were involved in each ESI also participated in a post-intervention debriefing for the above ESIs within 24 hours.
2. A record review was completed for Individual #3 on February 12, 2025. This review revealed that Individual #3 experienced ESIs on the following dates:
-December 26, 2024, at 10:05 PM
-December 26, 2024, at 10:13 PM
-December 26, 2024, at 10:22 PM
-December 28, 2024, at 7:21 PM
-January 4, 2025, at 8:40 PM
-January 6, 2025, at 5:49 PM
This review failed to reveal documentation that all staff who were involved in each ESI also participated in a post-intervention debriefing for the above ESIs within 24 hours.
An interview was conducted with the associate chief executive officer (ACEO) on February 13, 2025 at 9:00 AM. During this interview, the ACEO confirmed that there was no documentation to verify that all staff involved in the above ESIs for Individuals #2 and #3 also participated in a post-intervention debriefing within 24 hours.
Plan of Correction:POC 5 - Obs. #0189
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o The Associate Chief Executive Officer (ACEO) and the Evidence Based Coordinator (EBC), along with all Administrators and Program Supervisors (PS) affiliated with RTF care shall receive training with the regulation via review. The ACEO and EBS will follow-up with the Chief Executive Officer (CEO), relative to a supervisory and/or administrative debrief within 24 hours after the use of restraint or seclusion for all staff involved in the emergency safety intervention. This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
Requirement: the ACEO and EBC shall bring to this meeting the rationale as to why the debrief timeframes were not met, what barriers were experienced, and possible mitigating action responses. This shall be a focal point for discussion.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The ACEO and EBC will require supervisory staff to review to ensure that the debrief is facilitated in a timely manner aligned to the regulation.
o The ACEO will identify strategies to mitigate this issue.
o A summary report shall be forwarded to the Director of Compliance (DOC) by April 1st, 2025.
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Three corrective measures will be taken:
A review of the restraint Policy and documentation process.
Update to the Electronic Health Records to record more accurately in the documentation relative to this POC.
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
o The ACEO shall direct PS to review each hold per month to validate the correct application of the 24hr. debriefing regulatory requirements. They will collectively provide a Monthly, April 2025 – June 2025, summary report to the DOC, who shall update the CEO in July 2025 to review this process.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
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 review of facility training documentation and interview, it was determined that the facility failed to ensure that all staff demonstrated their competencies on a semiannual basis in safe crisis management. This applied to two of 13 staff training records reviewed. Findings included:
Review of facility provided staff training records was completed on February 10, 2025. This review revealed two staff that did not complete training to demonstrate their competencies in the area of safe crisis management on a semiannual basis.
Interview with the human resource coordinator on February 10, 2025, at 12:20 PM confirmed that there was no documentation that the two above staff demonstrated their competencies in the area of safe crisis management on a semiannual basis.
Plan of Correction:POC 6 - Obs. #0222
1. How corrective actions will be accomplished for those individuals identified in the deficiency statements.
o Program Supervisors (PS) and staff who may need to use Safe Crisis Management shall review the appropriate training requirements via a regulatory review. The PS will follow-up with the Associate Chief Executive Officer (ACEO) relative to ensuring all their staff are current and remain current with this regulation. This will serve as a check for understanding the regulation. Additionally, this will serve as a debrief to the specific situations identified within the DOH comments.
Requirement: the PS shall bring to this meeting the rationale as to why the debrief timeframes were not met, what barriers were experienced, and possible mitigating action responses. This shall be a focal point for discussion.
2. How the facility will identify other residents having the potential to be affected by the same deficient practice.
o The ACEO and Director of Human Resources (DHR) will require supervisory staff to review and maintain the quarterly training form submitted to the Director of Compliance (DOC).
o A summary report by the DOC shall be forwarded to Chief Executive Officer each quarter. When a PS report is showing error, the DOC will contact and inform the ACEO, who will follow up as warranted.
3. What corrective measures or systemic changes will be put into place to ensure that the deficient practice is being corrected and will not recur.
o Two corrective measures will be taken
A review of the training requirements for Safe Crisis Management by all program staff shall occur by April 1, 2025.
An action plan for ongoing review, outlined in the next section.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
o The DOC shall inform the ACEO and DHR if the PS quarterly training submission is deficient. This process shall have no end-date.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
o The DOC is responsible for ensuring this plan of correction moves forward with precision.
6. How substantial compliance will be measured.
o This POC shall be measured by completion of the tasks.
o Regulatory Compliance outcomes.
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