Initial Comments:
A validation survey was conducted July 8-12, 2024, 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 eight and the sample consisted of four individuals.
Plan of Correction:
441.184(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of facility provided staff training records and interview, it was determined that the facility failed to ensure that all staff were trained on the facility's emergency preparedness plan (EPP) at least every two years. This applied to 10 of 10 staff at the facility. Findings included:
A review of facility provided staff training records, for staff hired more than two years ago, was completed on July 12, 2024. This review failed to reveal training for 10 staff on the facility's EPP at least every two years.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:07 AM. The DRS confirmed that the facility had no documentation that these 10 staff were trained at least every two years on the facility's EPP.
Plan of Correction:-All YTC employees will review the Journey Emergency Preparedness Plan (EPP) as well as the site specific EPP with their supervisor.
-All new BLBHS residential employees will review the Journey Emergency Preparedness Plan (EPP) as well as their site specific EPP during Basecamp Orientation (1st week of employment). An attestation will be loaded into Relias upon completion for verification.
-Training plans will be updated to require all BLBHS residential employees to review the Journey EPP as well as their site specific EPP on a yearly basis in perpetuity, with an attestation for verification.
-Relias transcripts and training reports will be reviewed to ensure compliance during monthly safety meeting.
Annually, all residential employees will review the Journey Emergency Preparedness plan as well as their site specific Emergency Preparedness plan.
-This will be an ongoing activity.
Adherence to this plan will be monitored by Director of Residential Services during safety meeting on a monthly basis, and verified via safety meeting minutes and Relias training transcripts.
-Corrective Action will be completed by 01/01/2025.
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 staff training records and interview, it was determined that the facility failed to ensure that all staff were initially trained on the facility's emergency preparedness plan (EPP). This applied to five of 21 staff at the facility. Findings included:
A review of facility provided staff training records, for staff that were hired in the past two years, was completed on July 12, 2024. This review failed to reveal initial training for five staff on the facility's EPP.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:08 AM. The DRS confirmed that there was no documentation that five staff had been initially trained on the facility's EPP.
Plan of Correction:-All YTC employees will review the Journey Emergency Preparedness Plan (EPP) as well as the site specific EPP with their supervisor.
-All new BLBHS residential employees will review the Journey Emergency Preparedness Plan (EPP) as well as their site specific EPP during Basecamp Orientation (1st week of employment). An attestation will be loaded into Relias upon completion for verification.
-Training plans will be updated to require all BLBHS residential employees to review the Journey EPP as well as their site specific EPP on a yearly basis in perpetuity. Staff will complete and attestation in Relias for verification that the site specific EPP has been reviewed.
-This is an ongoing activity. Adherence to this plan will be monitored by Director of Residential Services during safety meeting on a monthly basis, and verified via safety meeting minutes and Relias training transcripts.
-Corrective Action will be completed by 01/01/2025.
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 review of facility provided documentation and interview, it was determined that the facility failed to conduct an additional exercise of the facility's emergency preparedness plan (EPP). This applied to all individuals at the facility. Findings included:
Review of facility provided emergency preparedness documentation was completed on July 12, 2024. This review revealed that the facility experienced an emergency that required activation of the facility's EPP on January 14, 2024. Further review failed to reveal that an additional exercise was also completed within the previous 12 months.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:11 AM. The DRS confirmed that no additional exercise was completed for the facility within the previous 12 months.
Plan of Correction:-Safety Committee will establish a date for drill or tabletop exercise during the August 2024 meeting. Drill/Tabletop exercise will be completed.
-Safety Meeting agenda will include a standing item as reference to annual completion of 2 drills and/or tabletop exercises for all BLBHS PRTFs. The agency will plan to conduct at least 2 drills annually for any program that has not experienced an actual event. All actual events will be properly reviewed/debriefed and documentation will be saved on the network in a central location.
- This will be an ongoing activity.
Adherence to this plan will be monitored by Director of Residential Services during safety meeting on a monthly basis, and verified via safety meeting minutes with a completed drill or tabletop exercise.
-Corrective Action will be completed by 01/01/2025.
Initial Comments:
A validation survey was conducted July 8-12, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities. The census during the survey was eight and the sample consisted of four individuals.
Plan of Correction:
483.358(d) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse, while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must verify the verbal order in a signed written form in the resident's record. The physician or other licensed practitioner permitted by the state and the facility to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all verbal orders for emergency safety interventions (ESIs) were verified and signed by the ordering practitioner. This applied to one (#2) of four individuals in the survey sample. Findings included:
Record review for Individual #2 was completed on July 11, 2024. This review revealed that Individual #2 experienced an ESI on February 8, 2024, at 7:04 PM. Review of the order for this ESI failed to reveal that it was verified and signed by the ordering practitioner.
An interview was conducted with director of residential services (DRS) on July 12, 2024, at 10:23 AM. The DRS confirmed that the order for the February 8, 2024, ESI was not verified and signed by the ordering practitioner.
Plan of Correction:-Training will occur with all practitioners on appropriately signing orders. This process will be monitored and reviewed on a weekly basis by the Program Manager and reported quarterly in Performance Improvement Council (PIC). The ordering practitioner for the events in question will verify and sign those orders.
-Program nursing staff will be required to review that all orders have been verified/signed for any ESI.
- This is an ongoing process. Adherence to this plan will be monitored by Director of Residential Services and the Director of Nursing, and will be evidenced by PIC minutes and appropriately signed orders.
-Corrective Action will be completed by 01/01/2025.
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 face-to-face comprehensive physical assessments occurred within one hour of emergency safety interventions (ESIs). This applied to all individuals in the survey sample. Findings included:
1. A record review for Individual #1 was completed on July 11, 2024. This review revealed that Individual #1 experienced an ESI on April 9, 2024 at 4:14 PM. Documentation for this ESI revealed that the assessment took place over Zoom with the assistance of facility staff. Further review revealed that the individual reported pain to bilateral biceps, being unable to move legs, and had pain to bilateral lower legs.
2. A record review for Individual #2 was completed on July 11, 2024. This review revealed that Individual #2 experienced ESIs on the following dates:
-April 13, 2024, at 10:32 AM.
-May 5, 2024, at 6:14 PM.
A review of the nursing assessment documentation for the ESIs revealed that the assessments took place over Zoom with the assistance of facility staff.
3. A record review for Individual #3 was completed on July 11, 2024. This review revealed that Individual #3 experienced ESIs on the following dates:
-June 23, 2024, at 6:26 PM
-June 23, 2024, at 2:13 PM
-February 29, 2024, at 6:27 PM
A review of the nursing assessment documentation for the ESIs revealed that the assessments took place over Zoom with the assistance of facility staff.
4. A record review for Individual #4 was completed on July 11, 2024. This review revealed that Individual #4 experienced ESIs on the following dates:
-July 3, 2024, at 6:06 PM
-June 21, 2024, at 7:19 PM
-April 26, 2024, at 4:41 PM
-March 1, 2024, at 5:58 PM
A review of the nursing assessment documentation for the ESIs revealed that the assessments took place over Zoom with the assistance of facility staff.
Further review of the documentation for the March 1, 2024, ESI revealed that Individual #4 hit their head off of a staff's head during the ESI and had a headache and a nosebleed. Neurological checks were completed with assistance of staff. Further review of the documentation for the June 21, 2024, ESI revealed that Individual #4 reported injury to left upper arm, right upper arm, right shoulder, and left hand.
An interview was conducted with director of residential services (DRS) on July 12, 2024, at 10:22 AM. The DRS confirmed that face-to-face comprehensive physical assessments did not occur for the four individuals for the above ESIs. The DRS further confirmed that it was the facility's practice to utilize Zoom following an ESI to complete face-to-face comprehensive physical assessments of individuals if a registered nurse was not in-person at the facility.
Plan of Correction:-Clients will be assessed by on call nursing personnel in a face to face manner. In the event that on call nursing personnel are not available for scheduling of face to face assessments, all clients will be transported to a local emergency room/Urgent Care facility in order for completion of face to face assessment.
-All residential nurses and staff will be formally retrained to this change in procedure. Informal training has been completed.
-This is an ongoing process. This process will be monitored and reviewed on a weekly basis by the Program Manager and reported quarterly in Performance Improvement Council (PIC). Adherence to this plan will be monitored by Director of Residential Services.
-A nursing assessment has been completed on multiple occasions for each of the identified individuals since the ESI, with no identified concerns.
-Corrective action will be completed by 01/01/25 *
Please note: This process was changed during the audit and all assessments have been completed face to face since 7/9/2024.
483.358(g)(2) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Each order for restraint or seclusion must include] the date and time the order was obtained; and
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all verbal orders for an emergency safety intervention (ESI) included the date and time the order was received by the by the nurse. This applied to one (#2) of four individuals in the survey sample. Findings included:
Record review for Individual #2 was completed on July 11, 2024. This review revealed that Individual #2 experienced an ESI on February 8, 2024, at 7:04 PM. Review of the order for this ESI indicated that the verbal order was obtained February 9, 2024, at 7:06 PM.
An interview was conducted with director of residential services (DRS) on July 12, 2024, at 10:22 AM. The DRS stated that the documented date and time was incorrect and that the order was actually obtained at the time the ESI occurred. The DRS confirmed that the date and time documented on the order did not match the date and time the order was actually obtained.
Plan of Correction:-Training will occur with all nursing staff responsible for obtaining restraint orders from the practitioner to ensure orders are obtained timely and accurately. This will include training for nursing staff to date and time each entry, and verify these for accuracy.
-The documentation in question will not be altered however a copy of this POC will be maintained on file for review as needed.
-Nursing staff will review all ESI orders for accuracy and completion.
-This is and ongoing process. This process will be monitored by Director of Nursing, reported quarterly at Performance Improvement Council (PIC), and evidenced by PIC meeting minutes and correct orders filed.
-Corrective action will be completed by 01/01/2025.
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 reviews and interview, it was determined that the facility failed to ensure that all orders for emergency safety interventions (ESI) included the specific restraints and specific length of time for which the intervention was permitted by the ordering physician. This applied to two (#2 and #3) of four individuals in the survey sample. Findings included:
1. Record review for Individual #2 was completed on July 11, 2024. This review revealed the following:
Individual #2 experienced an ESI on June 18, 2024, at 4:27 PM. This review revealed an ESI physician's order for multiple supine extension and cradle seated/kneeling therapeutic holds. This review further revealed that facility staff additionally implemented a hook/carry transport therapeutic hold.
Individual #2 experienced an ESI on May 16, 2024, at 5:36 PM. This review revealed an ESI physician's order for a multiple supine extension therapeutic hold. This review further revealed that facility staff additionally implemented a cradle seated/kneeling therapeutic hold.
2. Record review for Individual #3 was completed on July 11, 2024. This review revealed the following:
Individual #3 experienced an ESI on June 30, 2024, at 10:27 AM. This review revealed an ESI physician's order for multiple supine extension, upper torso seated/kneeling multiple, and cradle seated/kneeling therapeutic holds. This review further revealed that facility staff additionally implemented a upper torso assist therapeutic hold.
Individual #3 experienced an ESI on May 12, 2024, at 4:47 PM. This review revealed an ESI physician's order for a length of four minutes. This review further revealed that staff implemented the ESI for 14 minutes.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:24 AM. The DRS confirmed that the above additional therapeutic restraint holds used by staff were not included in the orders from the physician. The DRS stated that the time documented on the May 12, 2024, order was incorrect. The DRS further confirmed that during the ESI implemented on May 12, 2024, staff implemented the ESI beyond the time documented on the order from the physician.
Plan of Correction:-Training will occur with all nursing staff responsible for obtaining restraint orders from the practitioner to ensure orders are obtained timely and completed accurately. This training will be completed by 8/2/2024.
-Training will occur with all staff to ensure that only holds that are ordered by physician are implemented. This training will be completed by 8/2/2024.
-During daily review of restraint documentation, Program Manager will alert Director of Nursing if an issue exists with the order. Director of Nursing will meet with the respective nurse or alert the practitioner to the issue, to allow for consultation and documentation. Program Manager will alert Director of Residential Services and Director of Nursing if a hold is implemented that wasn't ordered, and will immediately meet with the staff involved to determine the steps necessary to correct.
-This will be an ongoing activity. This process will be monitored by Director of Residential Services, reported quarterly at Performance Improvement Council, and evidenced by PIC meeting minutes and congruent orders and implementation of holds.
-Corrective Action will be completed by 01/01/2025.
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 review and interview, it was determined that the facility failed to ensure that all licensed practitioners who ordered an emergency safety intervention (ESI) contacted the individual's treatment team physician. This applied to two (#2 and #3) of four individuals in the survey sample. Findings included:
1. Record review for Individual #2 was completed on July 11, 2024. This review revealed that Individual #2 experienced an ESI on February 8, 2024. This review failed to reveal documentation that the licensed practitioner who ordered this ESI contacted the treatment team physician for this individual to inform them of the ESI.
2. Record review for Individual #3 was completed on July 11, 2024. This review revealed that Individual #3 experienced ESIs on June 23, 2024, at 2:13 PM and 6:26 PM. This review failed to reveal documentation that the licensed practitioner who ordered these ESIs contacted the treatment team physician for this individual to inform them of the ESIs.
An interview with the director of residential services (DRS) on July 12, 2024, at 10:23 AM, confirmed that there was no documentation that the licensed practitioner, for the above ESIs ordered for Individual #2 and #3, contacted the treatment team physician to inform them of the ESIs.
Plan of Correction:-Program Manager will be retrained to thoroughly review clinical documentation, to include communication between physicians as part of restraint documentation. This training will be completed by 8/2/2024.
-The Clinical Team reviews all ESI's with the Treatment Team physician, who is aware of these events.
-During daily review of restraint documentation, Program Manager will notify Director of Nursing if evidence of consultation between practitioners is missing and Director of Nursing will notify the ordering physician to allow for consultation and documentation.
-This is an ongoing process. This process will be monitored by Director of Residential Services, reported quarterly at Performance Improvement Council, and evidenced by PIC meeting minutes and documented communication between practitioners.
-Corrective Action will be completed by 01/01/2025.
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 completed with the individual within 24 hours of the emergency safety intervention (ESI). This applied to all individuals in the survey sample. Findings included:
1. A record review was completed for Individual #1 on July 11, 2024. This review revealed the following:
- Individual #1 experienced an ESI on March 26, 2024, at 7:39 PM. This review revealed that a face-to-face discussion occurred on March 27, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #1 experienced an ESI on June 11, 2024, at 3:02 PM. This review revealed that a face-to-face discussion occurred on June 12, 2024. Further review failed to reveal the time that this discussion took place.
2. A record review was completed for Individual #2 on July 11, 2024. This review revealed the following:
- Individual #2 experienced an ESI on May 5, 2024, at 6:14 PM. This review revealed that a face-to-face discussion occurred on May 6, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #2 experienced an ESI on June 18, 2024, at 4:27 PM. This review revealed that a face-to-face discussion occurred on June 19, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #2 experienced an ESI on June 30, 2024, at 12:51 PM. This review revealed that a face-to-face discussion occurred on July 1, 2024. Further review failed to reveal the time that this discussion took place.
3. A record review was completed for Individual #3 on July 11, 2024. This review revealed the following:
- Individual #3 experienced an ESI on March 30, 2024, at 2:42 PM. This review revealed that a face-to-face discussion occurred on March 31, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #3 experienced an ESI on May 17, 2024, at 2:42 PM. This review revealed that a face-to-face discussion occurred on May 18, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #3 experienced an ESI on May 19, 2024, at 3:05 PM. This review revealed that a face-to-face discussion occurred on May 20, 2024. Further review failed to reveal the time that this discussion took place.
4. A record review was completed for Individual #4 on July 11, 2024. This review revealed the following:
- Individual #4 experienced an ESI on March 1, 2024, at 5:58 PM. This review revealed that a face-to-face discussion occurred on March 2, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #4 experienced an ESI on April 26, 2024, at 4:41 PM. This review revealed that a face-to-face discussion occurred on April 27, 2024, at 6:49 PM.
- Individual #4 experienced an ESI on June 17, 2024, at 6:46 PM. This review revealed that a face-to-face discussion occurred on June 18, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #4 experienced an ESI on June 21, 2024, at 7:19 PM. This review revealed that a face-to-face discussion occurred on June 22, 2024. Further review failed to reveal the time that this discussion took place.
- Individual #4 experienced an ESI on July 3, 2024, at 6:06 PM. This review revealed that a face-to-face discussion occurred on July 4, 2024. Further review failed to reveal the time that this discussion took place.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:21 AM. The DRS confirmed that there was no documentation that the face-to-face discussions occurred within 24 hours of the above ESIs for all four individuals.
Plan of Correction:-Clients identified missing debrief for a period of 14 days prior to the audit will be given an opportunity, if willing, to complete a client debriefing form. The facility will discuss the lack of completed client and staff debriefing during Crisis Management Committee Meeting (7/31/2024).
-Training will be provided to all staff to review the regulations and importance of client and staff debriefings. Training will be completed by 8/2/2024.
-The Program Manager will ensure that all debriefing forms are present when the ESI report is reviewed.
-This is an ongoing process. This process will be reviewed during the Crisis Management Committee on a monthly basis, monitored by Director of Residential Services, and reported quarterly during Performance Improvement Council (PIC). Corrective action will be evidenced by review of Crisis Management/PIC meeting minutes and completed debriefings within 24 hours.
-Corrective Action will be completed by 01/01/2025.
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 three (#2, #3, and #4) of four individuals in the survey sample. Findings included:
1. A record review was completed for Individual #2 on July 11, 2024. This review revealed that Individual #2 experienced ESIs on the following dates:
-June 18, 2024, at 4:27 PM
-May 5, 2024, at 6:14 PM
This review failed to reveal documentation that all staff participated in each post-intervention debriefing for the above ESIs within 24 hours.
2. A record review was completed for Individual #3 on July 11, 2024. This review revealed that Individual #3 experienced ESIs on the following dates:
-June 23, 2024, at 6:26 PM
-June 23, 2024, at 2:13 PM
-June 9, 2024, at 9:45 AM
-May 25, 2024, at 4:59 AM
-May 19, 2024, at 3:05 PM
-May 17, 2024, at 2:42 PM
-May 14, 2024, at 12:33 PM
-May 12, 2024, at 4:47 PM
-March 30, 2024, at 2:42 PM
-February 29, 2024, at 6:27 PM
This review failed to reveal that each post intervention debriefing occurred within 24 hours or documentation that all staff participated in each post-intervention debriefing for the above ESIs within 24 hours.
3. A record review was completed for Individual #4 on July 11, 2024. This review revealed that Individual #4 experienced ESIs on the following dates:
-July 3, 2024, at 6:06 PM
-June 29, 2024, at 2:12 PM
-June 21, 2024, at 7:19 PM
-May 13, 2024, at 4:00 PM
-April 26, 2024, at 4:41 PM
-March 1, 2024, at 5:58 PM
-February 8, 2024, at 3:58 PM
This review failed to reveal that each post intervention debriefing occurred within 24 hours or documentation that all staff participated in each post-intervention debriefing for the above ESIs within 24 hours.
An interview was conducted with the director of residential services on July 12, 2024 at 10:24 AM. The DRS confirmed that the above post-intervention staff de-briefings for Individuals #2, #3, and #4 either did not occur within 24 hours of the ESI, or that the documentation failed to indicate that the post-intervention staff de-briefing occurred within 24 hours of the ESI.
Plan of Correction:-Staff identified missing debrief for a period of 14 days prior to the audit will meet with their supervisor to debrief and document the discussion. The program manager will ensure all debriefing forms are present when the ESI is reviewed.
-The facility will discuss the lack of completed client and staff debriefing during Crisis Management Committee Meeting (7/31/2024).
-Training will be provided to all staff to review the regulations and importance of client and staff debriefings, with training to be completed by 8/2/2024.
-This will be an ongoing activity. This process will be monitored during the Crisis Management Committee on a monthly basis, monitored by Director of Residential Services, and reported quarterly during Performance Improvement Council (PIC). Corrective action will be evidenced by review of Crisis Management/PIC meeting minutes and completed debriefings within 24 hours.
-Corrective Action will be completed by 01/01/2025
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 staff training records and interview, it was determined that the facility failed to ensure that all staff were trained and demonstrated competencies in safe crisis management (SCM) on a semiannual basis. This applied to five of 31 staff training records reviewed. Findings included:
A review of facility provided staff training records for 31 staff was completed July 11, 2024. This review revealed that five of the 31 staff were not trained in SCM on a semiannual basis.
An interview was conducted with the director of residential services (DRS) on July 12, 2024, at 10:18 AM. The DRS confirmed that the five staff had not been trained in SCM on a semiannual basis.
Plan of Correction:-Staff members out of compliance have since completed SCM training and compliance.
-Any staff member falling out of compliance with semi-annual SCM review training will not participate in any SCM holds, will not be left alone with any clients. A supervision note will be filed to reflect the restriction, as well as the date of the next scheduled training which the employee will attend.
-Program Manager/Supervisor will generate a monthly report to include all pending (within 30 days) and past due trainings. Program Manager/Supervisor will ensure staff is scheduled to complete training as indicated, and will provide feedback to staff.
-Training compliance will be reported out during monthly Program Manager group supervision and identified deficiencies will be reviewed during biweekly individual supervision with Program Manager.
-Director of Residential Services will document the results of individual and group supervision in a conference note to include notification of those with pending training deadlines, identified deficiencies, and timelines for correction. Professional Development Specialists and other certified SCM trainers will be consulted and utilized to achieve training compliance as needed.
-This will be an ongoing activity. This process will be monitored by Director of Residential Services, evidenced by achievement of 100% training compliance as noted in the employee record via Relias transcripts.
-Corrective Action will be completed by 01/01/2025.
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