Initial Comments:
A validation survey was conducted August 3 - 4, 2022, 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)(5) STANDARD
Policies/Procedures for Medical Documentation
Name - Component - 00
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).
[(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:]
[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.
*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Based on policy review and interview, it was determined that the facility failed to develop an emergency preparedness plan to include policies and procedures for medical documentation. This applied to all of the residents at the facility. Findings included:
A review of facility's policies on emergency preparedness was completed on August 4, 2022. This review revealed the facility failed to develop an emergency preparedness plan and policy to include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency event.
An interview with the director of behavioral health was completed on August 4, 2022, at 12:45 PM, confirmed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records was not included in the emergency plan or policy of the facility.
Plan of Correction:1.HIM Director and IT Director to update the Emergency Contingency Plan to identify a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency event by 08/25/2022.
2.Approval of Emergency Contingency Plan by Safety Risk Committee at next scheduled meeting, 08/25/22.
3.Approval of Emergency Contingency Plan by Medical Records Committee at next scheduled meeting, 09/20/ 2022.
4.Approval of Emergency Contingency Plan by Staff Executive Committee at next scheduled meeting, 10/18/ 2022.
5.Approval of updated Emergency Contingency Plan by Board of Trustees at next scheduled meeting 12/13/2022 by Board of Trustees.
6.Staff Educator and PRTF Supervisor to train PRTF staff on updated Emergency Contingency Plan and MCH Nursing policy M-26 "Utilizing paper medication administration record in the event of technological failure" by 09/30/2022.
7.Chief Operating Officer to include medical documentation in next emergency operations exercise no later than 09/30/2022 and at least annually thereafter.
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 policy and plan review and interview, it was determined that the facility failed to develop an emergency preparedness plan to include the facility role under a waiver declared by the Secretary of the Department of Health, to include providing care at alternate care sites during emergencies. This applied to all the residents at the facility. Findings included:
A review of the facility's policy and plan was completed on August 4, 2022. This review revealed that facility's emergency preparedness plan failed to include the facility's role under a waiver declared by the Secretary of the Department of Health, to include providing care at alternate care sites during emergencies.
Interview with the director of behavioral health on August 4, 2022, at 12:45 PM, confirmed the facility's emergency preparedness plan failed to include the facility's role under a waiver declared by the Secretary of the Department of Health, to include providing care at alternate care sites during emergencies.
Plan of Correction:1. CEO will update Hospital policy No.
002 "Administrative Policies" to
include a process to follow waivers
declared by the Secretary of the
Dept. of Health for alternative care
sites on 08/19/2022.
2. PRTF Supervisor to train PRTF staff
on modified policy MCH
"Administrative Policy Number 002"
using an electronic management
system by 09/30/2022.
3. Staff Educator will audit employee
training files referencing the
updated MCH "Administrative Policy
Number 002" until 100% completion.
4. Program Director to report audit
findings to Medical Records Committee
on next scheduled meeting,
10/18/2022.
5. Approval of update with training for
MCH "Administrative Policy Number
002" by Staff Executive Committee at
next scheduled meeting, 11/15/2022.
6. Approval of update with training for
MCH "Administrative Policy Number
002" by Board of Trustees at next
scheduled meeting 12/13/2022.
Initial Comments:
A validation survey was conducted August 3 - 4, 2022, 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 seven and the sample consisted of four individuals.
Plan of Correction:
483.356(d) ELEMENT
PROTECTION OF RESIDENTS
Name - Component - 00
Contact information. The facility's policy must provide contact information, including the phone number and mailing address, for the appropriate State Protection and Advocacy organization.
Observations:
Based on review of facility policy, record review, and interview, it was determined that the facility failed to ensure that the contact information, including the phone number and mailing address, for the state protection and advocacy organization was provided to the resident or parent/guardian at the time of admission. This applied to all the residents at the facility. Findings included:
Record review of the four sample records were completed on August 4, 2022. This review failed to reveal that the state protection and advocacy contact information was provided to resident, or parent/guardian upon the time of each admission. Further review of the facility policy failed to reveal that it is the policy of the facility to provide the contact information for the state protection and advocacy at the time of a resident's admission.
Interview with the progam supervisor on August 4, 2022, at 10:14 AM, confirmed that it is not the current practice nor it is in the facility policy, to provide the state protection and advocacy contact information, including the mailing address and phone number, to the residents or the parent/guardian at the time of admission.
Plan of Correction:1.PRTF Supervisor updated the advocacy informational handout to include the contact information for the appropriate state protection and advocacy organization by 08/11/22.
2.Approval of modified advocacy informational handout by the Medical Records Committee on next scheduled meeting, no later than 09/30/2022.
3.Approval of modified advocacy informational handout by Staff Executive Committee at next scheduled meeting, 10/18/ 2022.
4.Approval of modified advocacy informational handout by the Board of Trustees on 12/13/2022.
5.PRTF Supervisor created the Intake/Admission Protocol Policy pRTF I-3, Intake/Admission Process to include providing information for the state protection and advocacy organization on 08/16/2022.
6.Staff Educator and PRTF Supervisor created and completed training with all pRTF staff members by 08/17/22.
7.PRTF Supervisor to provide current residents and guardians with modified informational handout by 09/07/22.
8.PRTF Supervisor to post modified informational handout in display case on the unit by 08/26/22.
9.PRTF Supervisor to Audit 100% of admissions for the next 60 days or to achieve 100% compliance, whichever is later.
10.PRTF Supervisor to Track audit findings on PRTF Quality Dashboard.
11.Program Director to report audit findings to Performance Improvement Committee on next scheduled 11/15/2022 meeting.
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 review of facility policy and interview, it was determined that the facility failed to ensure that a face to face assessment was completed for the resident within one hour of initiation of an emergency safety intervention. This applied to all the residents at the facility. Findings included:
Review of the facility policy on August 3, 2022, failed to reveal that it is the policy of the facility that a face to face assessment was completed for the resident within one hour of initiation of an emergency safety intervention. The current facility policy states that the assessment will occur "within one hour of the removal" of the procedure.
Interview with the progam supervisor on August 3, 2022, at 1:30 PM, confirmed that it is not the current facility policy to complete the face to face assessment of the resident within one hour of initiation of the emergency safety intervention.
Plan of Correction:1.PRTF Supervisor updated Policy pRTF policy R-1 Restrictive Procedures and changed language from "within one hour of removal" to "within one hour of initiation" of the restrictive procedure by 08/16/22.
2.Approval of policy updates by PRTF Medical Director on 08/19/22.
3.PRTF Supervisor and Staff Educator created and completed training with pRTF staff members on 8/17/22.
4.PRTF Program Director to create and complete training with physicians who have occasion to complete the face to face assessment by 09/07/22.
5.PRTF Supervisor to Audit 100% of restrictive procedures.
6.PRTF Supervisor to Track audit findings on PRTF Quality Dashboard.
7.Program Director to Report audit findings to Performance Improvement Committee on next scheduled meeting 11/15/2022.
483.376(b) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Certification in the use of cardiopulmonary resuscitation, including periodic recertification, is required.
Observations:
Based on facility provided staff training records and interview, it was determined that the facility failed to ensure that all staff were trained in cardiopulmonary resuscitation. This applied to three of 14 training records reviewed. Findings included:
A review of facility provided staff training records were completed on August 3, 2022. This review revealed that three of the 14 staff were not trained in the use of cardiopulmonary resuscitation.
Interview with the human resource director on August 3, 2022, at 12:30 PM, confirmed that three staff were not training in the use of cardiopulmonary resuscitation.
Plan of Correction:1.Two pRTF staff members completed CPR training on 08/19/2022, third per- diem staff member will not be scheduled to work until CPR training completion.
2.Human Resources will use an electronic tracking mechanism to track CPR expiration dates by 9/30/22.
3.Human Resources will notify staff member and supervisor of upcoming expiration date, 30 days in advance of expiration date.
4.Human Resources will Audit 100% of employee files for the next 60 days. Audit sampling annually thereafter.
5.Human Resources to Track audit findings on HR Quality Dashboard.
6.Human Resources to Report audit findings to Performance Improvement Committee on 11/15/2022.
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 facility provided staff training records and interview, it was determined that the facility failed to ensure that all staff demonstrated their competencies in safe crisis management on a semiannual basis. This applied to eight of 14 training records reviewed. Findings included:
A review of facility provided staff training records were completed on August 3, 2022. This review revealed that eight of the 14 staff were not trained on a semiannual basis in safe crisis management.
Interview with the human resource director on August 3, 2022, at 12:30 PM, confirmed that the training dates for the staff were the most current and eight of the 14 staff were not trained on a semiannual basis in safe crisis management.
Plan of Correction:1.PRTF Supervisor updated Policy R-1
Restrictive Procedures on 08/16/2022
to reflect that all PRTF staff will
demonstrate competency in safe crisis
management no less than every six
months.
2.In order to ensure that this happens
the restraint training utilized by the
pRTF "Handle With Care" which utilizes
safe crisis management and verbal de-
escalation techniques and when
necessary physical holds will be
trained no less than every six months
with all staff. All pRTF staff will
have demonstrated competency by
08/30/22. Staff educator will utilize
an electronic tracking system to
ensure staff competency at required
frequency is met.
3. PRTF Supervisor to complete training
with all PRTF staff on Policy R-1
Restrictive Procedures.
4.Staff educator to audit 100 % employee
files bi-annually to ensure competency
and training completion.
5.Program Director to report audit
findings to Medical Records Committee
on next scheduled meeting, 09/20/2022.
6.Approval of update with training for
"Policy R-1 Restrictive Procedures" by
Staff Executive Committee at next
scheduled meeting, 10/18/2022.
7.Approval of update with training for
"Policy R-1 Restrictive Procedures" by
Board of Trustees at next scheduled
meeting 12/13/2022.
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