Initial Comments:
A validation survey was conducted February 18 - 20, 2020, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities.
Plan of Correction:
441.184(b)(8) STANDARD
Roles Under a Waiver Declared by Secretary
Name - Component - 00
§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Based on a review of the facility's emergency preparedness (EP) plan, and interview, it was determined that the facility failed to ensure the plan addressed a waiver declared by the secretary, in accordance with section 1135 of the Act. Findings included:
A review of the facility's EP plan was completed on February 20, 2020. This review revealed that the facility failed to address a waiver declared by the secretary, in accordance with section 1135 of the Act.
Interview with the chief executive officer on Februay 20, 2020, at 9:00 AM, confirmed the facility did not include the waiver by the secretary in the EP plan.
Plan of Correction:This will be an exhibit in the Emergency Operation Plan for each of the Perseus House residential facilities.
It is the policy and procedure of Perseus House Inc. that in the event of an emergency, disaster mitigation/ relief (re 1135 Waiver) requiring the relocation of the agency population Perseus House Inc. will conform to the emergency management provisions within the venue of the relocation. As stipulated:
1135 Waiver: In the case of an emergency or disaster mitigation/or relief requiring the relocation of the agency population, Perseus House Inc., will comply with the primary emergency management provider in a local, regional, statewide or national emergency. Such compliance will include:
- Conditions of participation or other
certification requirements
- Program participation and similar
requirements
- Preapproval requirements
- Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only – state law governs whether a non-Federal provider is authorized to provide services in the state without state licensure)
- Emergency Medical Treatment and Labor Act (EMTALA) sanctions for redirection of an individual to receive a medical screening examination in an alternative location pursuant to a state emergency preparedness plan (or in the case of a public health emergency involving pandemic infectious disease, a state pandemic preparedness plan) or transfer of an individual who has not been stabilized if the transfer is necessitated by the circumstances of the declared emergency. A waiver of EMTALA requirements is effective only if actions under the waiver do not discriminate on the basis of a patient's source of payment or ability to pay.
- Stark self-referral sanctions
- Performance deadlines and timetables may be adjusted (but not waived).
- Limitations on payment to permit Medicare enrollees to use out of network providers in an emergency situation.
This policy is subject to the requirements of the National Emergencies Act, the Stafford Act, and any declaration issued by the HHS Secretary regarding public health emergencies, or any and all relevant local, state and federal declarations requiring compliance.
441.184(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of facility provided training records and interview it was determined that the facility failed to ensure that all staff are trained on the facility's emergency preparedness (EP) plan. This applied to five of 16 staff. Findings included:
Review of facility provided staff training records were completed on February 19, 2020. This review revealed that five staff were not trained on the facility's emergency preparedness (EP) plan
Interview with the human resource director on February 19, 2020, at 1:37 PM, confirmed that there were five staff not trained on the facility's emergency preparedness (EP) plan.
Plan of Correction:In response to the required clan of correction, the following has been an amendment in the Perseus House Girl's Enhanced Residential Treatment Facility Emergency Operations Plan. The amendments address the need for training and annual testing regarding the facility's emergency preparedness plan. This training and testing will include both full-scale drills and tabletop exercises.
"Emergency Operations Plans must be updated/revised, and exercised (tested). The EOP will be reviewed annually, and scrutinized subsequent to every emergency event (see After-Action Report). It will be exercised (full-scale community based) annually, along with a table-top exercise and unannounced random staff drills. The table-top exercise includes a group discussion lead by a facilitator, using a narrated, clinically-relevant emergency scenario and a set of problem statements and prepared questions designed to challenge the emergency plan. Changes or modifications to the emergency operations plan will be considered in relation to an after-action review. The review is specifically to analyze the facility's response. Documentation of all table-top exercises, drills and emergency events will be maintained.
As noted in the Promulgation Statement, Emergency Operation Plans are living documents; they need to be used and updated. The evolutionary process does not cease: times change, along with personnel experience and training. The safety of clients and staff ranks is a top priority of Perseus House in fulfilling its obligations to its constituency.
Perseus House staff will receive documented training emergency preparedness policies and procedures within 90 days of hire and annually thereafter. The documentation of the training will be on the employee's annual training plan as well as the Checklist for New Employees that is completed within the first 90 days of employment."
A contracted emergency management agency will conduct the annual "Emergency Preparedness" training and the testing of the Emergency Management Plan. The new employees will be trained by the staff that were trained by the contracted emergency management agency on the "Emergency Operations Plan".
The Chief Operating Officer will ensure that the training and testing is completed annually in coordination with a contracted emergency management agency.
The Perseus House documentation templates regarding the annual training plan and the new employee checklist have been amended to include this requirement.
The training and testing of the Emergency Operation Plan for Perseus House GERTF employees will be completed by 7/1/20.
The Chief Operating Officer in coordination with the Human Resources Department will ensure that all new employees have been trained in regard to the emergency preparedness plan. Every new employee has training requirements that must be completed within the first 90 days of their employment. These trainings, which include training and review of the emergency preparedness plan are documented on the "New Employee Checklist". Once the trainings are completed by the new employee, they are documented on the "New Employee Checklist". The new employee's specific supervisor must then turn in the completed "New Employee Checklist" to the Human Resources department. The Human Resources department reviews the staff files to ensure that the "new Employee Checklist" is completed and returned. If this form is not completed and returned, the Chief Operating Officer is notified. At that point the Chief Operating Officer will devise a plan that includes completion of the tasks still outstanding with the new employee and the direct supervisor of the new employee.
In regard to existing employees, the Perseus House annual training plan has been updated to include the emergency preparedness plan. The staff will be trained annually and this annual training date will be documented on the employee's annual training plan. The annual training plan is returned to the Human Resources Department to ensure that all of the required trainings have been completed. In the event that the trainings were not completed the Chief Operating Officer will be notified by the Human Resources department. A plan will be put in place between the employee with outstanding training and that employee's supervisor.
Please not that there is a system in place to monitor the employee's training progress throughout the year. Every Perseus House staff receives formal supervision at least two times a month. This formal supervision is documented through a Close and Direct (C & D) Supervision form. It is Perseus House process that at least one of the two formal supervision's that a staff member receive is about training needs and requirements. The C&D supervision forms are returned to the Perseus House Associate Executive Director and then to the Human Resources department.
The current plan remains for the staff to be trained and to participate in an emergency drill by the Perseus House contracted emergency preparedness agency by 7/1/20.
The Chief Operating Officer will maintain and monitor the completion of these tasks.
441.184(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on facility provided emergency preparedness (EP) documentation and interview it was determined that the facility failed to ensure that the facility participated in a full-scale exercise of the EP plan annually. Findings included:
Review of facility provided emergency preparedness documentation was completed on February 20, 2020. This review revealed that a EP table top exercise was completed in the past 12 months. This review failed to reveal that the facility participated in a full-scale exercise.
Interview with the chief executive officer on February 20, 2020, at 9:30 AM confirmed that the facility did not participate in an EP full-scale exercise.
Plan of Correction:The following has been an amendment in the Perseus House Girl's Enhanced Residential Treatment Facility Emergency Operations Plan. The amendments address the need for training and annual testing. This training will include both full-scale drills and tabletop exercises.
"Emergency Operations Plans must be updated/revised, and exercised (tested). The EOP will be reviewed annually, and scrutinized subsequent to every emergency event (see After-Action Report). It will be exercised (full-scale community based) annually, along with a table-top exercise and unannounced random staff drills. The table-top exercise includes a group discussion lead by a facilitator, using a narrated, clinically-relevant emergency scenario and a set of problem statements and prepared questions designed to challenge the emergency plan. Changes or modifications to the emergency operations plan will be considered in relation to an after-action review. The review is specifically to analyze the facility's response. Documentation of all table-top exercises, drills and emergency events will be maintained.
As noted in the Promulgation Statement, Emergency Operation Plans are living documents; they need to be used and updated. The evolutionary process does not cease: times change, along with personnel experience and training. The safety of clients and staff ranks is a top priority of Perseus House in fulfilling its obligations to its constituency.
Perseus House staff will receive documented training emergency preparedness policies and procedures within 90 days of hire and annually thereafter. The documentation of the training will be on the employee's annual training plan as well as the Checklist for New Employees that is completed within the first 90 days of employment."
A contracted emergency management agency will conduct the annual "Emergency Preparedness" training and the testing of the Emergency Management Plan. The new employees will be trained by the staff that were trained by the contracted emergency management agency on the "Emergency Operations Plan".
The Chief Operating Officer will ensure that the training and testing is completed annually.
Initial Comments:
A validation survey was conducted February 18 - 20, 2020, 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:
483.376(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 provided training records and interview it was determined that the facility failed to ensure that all staff are trained in safe crisis management (SCM) on a semi annual basis. This applied to two of 16 staff. Findings included:
Review of facility provided staff training records were completed on February 19, 2020. This review revealed that two staff were not trained on the facility's safe crisis management program on a semi annual basis.
Interview with the human resource director on February 19, 2020, at 1:37 PM, confirmed that there were two staff not trained in SCM on a semi annual basis.
Plan of Correction:483.376 (f) ELEMENT EDUCATION AND TRAINING
The facility failed to ensure that all staff are Safe Crisis Management (SCM) trained on a semi- annual basis.
Perseus House will ensure that all staff are Safe Crisis Management (SCM) trained on semi-annual basis.
The two identified staff that had not been trained were the facility nurses. Moving forward the nursing staff will become SCM training. The two identified staff that were not appropriately trained per the regulation are scheduled for training on March 13, 2020 and will complete the remainder of the training no later than April 30, 2020.
The Girls Enhanced Residential Treatment Facility (GERTF) supervisor and the nursing supervisor will continue to address ongoing staff training needs on a regular basis. These supervision discussions regarding training needs will be documented in the Perseus House Close and Direct Supervision document. Additionally, the staff member is to follow and document trainings on their individual annual training plan.
The SCM Training is scheduled in the following manner:
- SCM Training is offered monthly
- SCM Quarterly Skill Outs occur
- SCM Annual Refresher is planned
The staff associated with the GERTF residential facility will be trained and the facility director and nursing supervisor will monitor completion. If this training is not completed corrective action will occur to ensure SCM training certification.
In response to the recent rejection of our Plan of Correction our plan for monitoring the training needs are as follows; on a monthly basis the individual staff member's supervisor conducts formal supervision at a minimum of two times a month. It is Perseus House process that at least one time a month the provided supervision is to discuss and review the staff member's training needs and requirements. These supervision experiences for the employees (which include the nursing department) are documented on a Close and Direct (C & D) Supervision form. These C & D forms are reviewed by the Associate Executive Director and are filed with the Human Resources department.
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