Initial Comments:
A validation survey was conducted November 16-18, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted November 16-18, 2021, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was nine and the sample consisted of six individuals.
Plan of Correction:
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 a record review and interview, it was determined that the facility failed to ensure that all staff involved in a restraint, participated in a debriefing within 24 hours after the intervention. This applied to one individual (#1) in the sample that had been restrained. Findings included:
A record review for Individual #1 was completed on November 17, 2021. This review revealed that Individual #1 was restrained on July 1, 2021, for seven minutes. The documentation revealed that the staff involved were not debriefed until September 14, 2021.
An interview was conducted with the chief operating officer (COO) on November 17, 2021, at 9:05 AM. The COO confirmed that the staff debriefing session for Individual #1 was not completed within 24 hours of the restraint as expected.
Plan of Correction:After a Therapeutic Hold (TH) occurs, contact is made with the Program Supervisor. It is this initial contact that will ensure that the debriefing process begins. The debriefing process will include, the precipitating factors and the situations that led to the TH, and any other possible strategies or interventions that could be employed to avoid a future TH. The Program Supervisor will review the debriefing process with the staff during the initial contact so that the client debriefing occurs. The Program Supervisor will debrief with the staff if possible during the initial contact. If this debriefing cannot occur immediately, it will occur within the first 24 hours after the TH. Immediately following the TH and prior to the end of the staff's shift, the Therapeutic Restraint Special Incident Report (SIR) will be completed. Once the lead staff have signed the SIR in the client's electronic medical records (EMR) an alert to the Program Supervisor, the Clinical Director and the COO will be automatically sent. This alert will function as a way to follow and track the progress of the SIR process and the debriefing. It will be the Program Supervisor's responsibility to review the SIR and ensure that the debriefings have occurred correctly and in accordance with regulatory timeframe standards.
All Perseus House staff are responsible for understanding and utilizing this process and timeframe. The Program Supervisors will review and be trained on this process at the next Perseus House Executive Committee/Quality Council (EC/QC) meeting by the COO and the Clinical Director. The EC/QC meeting minutes are sent electronically to all PH staff members. The Program Supervisors conduct regular staff meetings for their facilities and the EC/QC meeting minutes are reviewed. The Clinical Director is present at both the EC/QC and staff meetings for clarification of the process and expectations. These identified areas of information sharing will confirm that all Perseus House staff have the information necessary to meet the timeframe standards.
The COO and the Clinical Director will be responsible for following the EMR alerts and the Therapeutic Hold notifications. The COO and Clinical Director and/or their designee will review the process and improvement with meeting the standards for debriefing timelines. If further deficiencies occur there will be continued supervision and training and if necessary instituting the disciplinary continuum.
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 a review of facility training records, it was determined that the facility failed to ensure all staff participating in restraints are current with safe crisis management (SCM) training. This applied to two staff. Findings included:
A review of staff training records was completed on November 17, 2021. This review revealed that two of 11 staff were not trained semi annually.
Interview with the human resource director on November 17, 2021, at 9:05 AM confirmed that the two staff were not trained on a semi annual basis.
Plan of Correction:Perseus House has the following process in place to ensure that staff are trained in Safe Crisis Management (SCM) techniques to meet the standards and guidelines of all licensing/governing entities/agencies:
There is monthly training in SCM for new hires to Perseus House
There is a scheduled semi - annual SCM refresher
There is an annual SCM refresher
There are Quarterly Skill Outs that are offered
The training calendar with all of these SCM training opportunities and reminders are forwarded to Program Supervisors regarding SCM training opportunities by individuals in the Human Resources HR department on a monthly or as needed basis.
Perseus House utilizes an online training platform, Relias. Relias will track trainings and provide alerts to the staff, the Program Supervisors and the designated HR individual. This alert will ensure that staff are trained within the regulatory guidelines. It will also allow supervisors to ensure that the staff that are not trained at least semi-annually will not be participating in any Therapeutic Holds (TH).
Perseus House HR Director and their designee has provided and will continue to provide training to all Perseus House staff and supervisors to ensure the effective utilization Relias in regard to SCM. All Perseus House staff are responsible for understanding their SCM training requirements. The Program Supervisors will review and be trained on this process at the next Perseus House Executive Committee/Quality Council (EC/QC) meeting by the HR Director or their designee. The EC/QC meeting minutes are sent electronically to all PH staff members. The Program Supervisors conduct regular staff meetings for their facilities and the EC/QC meeting minutes are reviewed. The HR Director is present at the EC/QC meetings for clarification of the process and expectations. This information sharing will confirm that all Perseus House staff have the information necessary to meet the timeframe standards.
The addition of Relias as well as the HR training tracking and updates will help to ensure that all staff are SCM trained to meet the standard of a semi-annual basis. The HR Director will be responsible to ensure that communication regarding staff's need for SCM training is occurs and is completed. The COO will coordinate with the HR Director to support the corrective action plan to ensure compliance with semiannual SCM training.
|