Initial Comments:
An initial validation survey visit was conducted on October 2 and 3, 2023. The purpose of this visit was to determine compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations for Medicare and Medicaid participating providers and suppliers. After many communications there was a delay in processing this out due to the Central Office receiving the CMS-1513 (January 19, 2024 at 10:33 a.m.); receiving newly filed d/b/a Devereux Pennsylvania Children's Services (January 18-19-2024 The PA Department of State, entity number 0013714177); receiving JCAHO (January 18, 2024 - Legal Name Change being worked on) and a request made on January 9, 2024 for an updated attestation document.
The ABH Pennsylvania Children's Services Inc.Brumer facility is in compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations for Medicare and Medicaid participating providers and suppliers.
Plan of Correction:
Initial Comments:
An initial validation survey visit was conducted on October 2 and 3, 2023. The purpose of this visit was to determine compliance with the Requirements of 42 CFR, Part 483, Subpart G Regulations for Psychiatric Residential Treatment Facilities for Children Under Age 21.
The census at the time of the visit was 23, and the sample consisted of eight residents. After many communications there was a delay in processing this out due to the Central Office receiving the CMS-1513 (January 19, 2024 at 10:33 a.m.); receiving newly filed d/b/a Devereux Pennsylvania Children's Services (January 18-19, 2024 The PA Department of State, entity number 0013714177); receiving JCAHO (January 18,2024 - Legal Name Change being worked on) and a request made on January 9, 2024 for an updated attestation document.
Plan of Correction:
483.358(a) STANDARD
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the State and the facility to order restraint or seclusion and trained in the use of emergency safety interventions. Federal regulations at 42 CFR 441.151 require that inpatient psychiatric services for beneficiaries under age 21 are provided under the direction of a physician.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure orders for restraints were ordered by a physician or other licensed practitioner permitted by the State and the facility for two of six sample Resident who were restrained. This practice is specific to Resident #3 and #6.
Findings include:
A review of the records for Resident #3 and Resident #6 was completed on 10/02/2023 from approximately 9:30 AM to 11:30 AM. This review revealed the following information :
Individual #3
A review of the record for Resident #3 revealed that he was restrained on 08/11/2023. This restraint was noted on a document titled, "Restraint Progress Note". This report indicates that Resident #3 was restrained using a"2 arm control escort - 2 person and a seated floor - 2 person " restraint (no start and end time documented on this restraint progress note.) Further review of this information noted that there was no evidence that a physician, or other licensed practitioner permitted by the State had ordered the use of this restraint.
Individual #6
A review of the record for Resident #6 revealed that he was restrained on 09/03/2023. This restraint was noted on the "Restraint Progress Note". This report indicates that Resident #6 was restrained using a "upper arm escort" which started at 12:45 PM for a duration of 2 minutes. Further review of this information noted that there was no evidence that a physician, or other licensed practitioner permitted by the State had ordered the use of this restraint.
Interview with the Quality Improvement Coordinator on 10/03/2023, at approximately
10:45 AM, confirmed that the facility was unable to verify that a physician's orders were obtained for the use of the above mentioned restraints.
Plan of Correction:1. N/A - Physician's orders for emergency safety interventions for Individuals #3 and 6 were not obtained following incidents of restraints.
2. 6 additional charts reviewed on 10.24.23 confirmed physician's orders present.
3. Program Supervisors/Treatment Managers were initially trained on requirements of the facility's procedure for restraints in the area of obtaining physician's orders on 7.28.23 regarding immediate notification to nursing department of a restraint. Retraining of the Program Supervisors/Treatment Managers occurred on 10.6.23 with additional training scheduled for 11.6.23. A retraining of the nursing department to ensure physician orders are obtained and documented will occur on 11.2.23.
4. The nurse manager (or designee) will conduct a first level review within 24 hours of a restraint to ensure order has been obtained and will scan a copy of the Physician Order to the Quality Improvement Department within 48 hours for secondary review. Quality Department will complete a second level review within 72 hours and provide written feedback to the Medical Director for follow up for any deficiencies identified during the secondary audit process. Medical Director will provide retraining to all physicians that do not meet the standard on a case by case basis as identified through the audit process that will begin on 11.6.23.
5. Oversight by Medical Director. For any deficiencies identified during Quality Department's second level review, Medical Director will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 a review of facility documents and interview with administrative staff, the facility failed to ensure that verbal orders for a restraint obtained during or immediately after the emergency situation ended, had been verified in a signed written form in the resident's record by the physician for two of six sample individual who had a verbal orders for a restraint.
This practice is specific to Individual #1 and #2.
Findings include:
A review of the record of Individual #1 and #2 was completed on 10/02/2023 between
9:30 AM and 11:30 AM and revealed the following;
Resident #1
A review of the record for Resident #1 revealed that he was restrained on 08/08/2023.
This restraint was noted on a document titled, "Restraint Progress Note" and
indicates that Resident #1 was restrained using a "Supine - arms at side - 3 person" restraint from 6:22 PM until 6:28 PM for a duration of six minutes. A review of the Physician' Order/Nursing Assessment section of this emergency safety invention (ESI) packet revealed that a verbal order was obtained on 08/08/2023 at 6:53 PM for the use of the above mentioned restraint for a duration of 30 minutes. Continued review of this verbal order revealed that the the ordering physician did not verify the verbal order by signing the order.
Resident #2
A review of the record for Resident #2 revealed that he was restrained on 07/11/2023.
This restraint was noted on a document titled, "Restraint Progress Note".
This report indicates that Resident #2 was restrained using a "Seated Floor - 1 person" restraint from 7:43 AM until 7:45 AM for a duration of two minutes. A review of the Physician' Order/Nursing Assessment section of this emergency safety invention (ESI) packet revealed that a verbal order was obtained on 07/11/2023 at 9:00 AM for the use of the above mentioned restraint for a duration of 30 minutes. Continued review of this verbal order revealed that the the ordering physician did not verify the verbal order by signing the order until 07/27/2023 at 12:00 PM.
A review of the agency's policy titled "Restraint Use In Residential Services" Policy # 212, page 10, revealed under the section titled, Documentation Requirements number 3(r):
-The physician ordering the physical restraint must sign any verbal order in the individual record within 72 hours.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately
11:18 AM, confirmed that the physician did not sign the verbal order for the restraint order for Resident #1 and the physician did not sign Resident #2's verbal order for restraint within the 72 hour time frame as noted in the facility's policy
Plan of Correction:1. N/A – Physician's orders for emergency safety interventions for Individuals #1 and 2 were not signed.
2. 6 additional charts reviewed on 10.24.23 confirmed physician's orders were signed within 72 hours.
3. Following receipt of order for restraint, nursing department will obtain the physician's signature within 72 hours either in person or through docu-sign. The nurse manager (or designee) will conduct a first level review within 24 hours from initiation of each order of restraint to ensure physician's order is obtained and will notify physician by phone if order is not yet signed. Retraining of nursing department to occur 11.2.23
4. The nurse manager (or designee) will conduct a first level review within 24 hours for each order of restraint to ensure physician's order is obtained and will submit a copy of the order to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Medical Director for follow up for any deficiencies identified during the secondary audit process. Medical Director will provide retraining to all physicians that do not meet the standard on a case by case basis as identified through the audit process that will begin on 11.6.23.
5. Oversight by Medical Director. For any deficiencies identified during Quality Department's second level review, Medical Director will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 a review of facility documents and interview with administrative staff, the facility failed to ensure that within one hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions (ESI) and permitted by the state and the facility to assess the physical and psychological well-being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the Resident. This practice is specific to Residents #2, #3, #4 and #6.
Findings include:
A review of Resident #2, #3, #4 and #6's records was completed on 10/02/2023 from approximately 9:30 AM to 11:30 PM. This review noted that a face to face assessment of physical and psychological well-being of the resident was not conducted within one hour after the restraint. Resident #1 and #3 are exemplary of that practice:
Resident #3:
A review of Resident #3's record revealed that this resident was restrained on 09/09/2023 at 4:51 PM until 4:56 PM. This restraint was documented on a form titled "Restraint Progress note". Further review of this packet revealed a form titled "Physician Order/Nursing Assessment. Under the section one hour face to face assessment of the physical and psychological well-being, it notes that Resident #3 was assessed by a nurse on 09/10/2023 at 7:15 AM, over the one hour time frame.
Resident #4
A review of Resident #4's record revealed that this resident was restrained on 09/18/2023 at 6:08 PM until 6:15 PM. This restraint was documented on a form titled "Restraint Progress note". Further review of this packet revealed a form titled "Physician Order/Nursing Assessment. Under the section one hour face to face assessment of the physical and psychological well-being, it notes that Resident #3 was assessed by a nurse on 09/18/2023, however there is no time documented to indicate this assessment occurred within the one hour time frame.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately
10:40 AM confirmed that the face to face assessment of the physical and psychological well-being was not conducted within one hour post restraint.
Plan of Correction:1. N/A – Face to face assessments were not completed within one hour after the restraint for Residents 2, 3, 4 and 6.
2. 3 additional charts reviewed on 10.24.23 confirmed face-to-face assessments were completed within one hour of initiation of emergency safety intervention.
3. Retraining of nurses on the facility's procedure for restraints in the area of face to face assessments will occur on 11.2.23 of requirement for one hour face to face assessments.
4. Immediately upon the initiation of a restraint, a call will be placed to the nursing department via walkie talkie or phone to alert the nurse of the restraint so an assessment can occur. When the nurse arrives to the unit for assessment, the nurse will verbally confirm the restraint(s) that were implemented to ensure there is no miscommunication about the need for assessment. The nurse manager (or designee) will conduct a first level review within 24 hours for each order of restraint to ensure a face to face assessment was completed by the nurse within one hour of initiation of an emergency safety intervention and will submit a copy of the nursing assessment to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Director of Nursing for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Nursing Director. For any deficiencies identified during Quality Department's second level review, Nursing Director will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
483.358(h)(2) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Documentation must include] the time the emergency safety intervention actually began and ended.
Observations:
Based on record review and interview with administrative staff, the facility failed to document the time emergency safety interventions actually started and ended for one of six sample Residents who were restrained. This practice is specific to Resident #3.
Findings include:
A review of the record of Resident #3 completed on 10/02/2023 between 9:30 AM and
11:30 AM, revealed a document titled "Restraint Progress Note" dated 08/11/2023. Under the section titled Emergency Intervention start/end times there is a space to record the time the restraint began and the time the restraint ended. Continued review of this document revealed that the start and end time of this restraint were left blank.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately 10:40 AM confirmed that the start and end times of the above mentioned restraints were not recorded.
Plan of Correction:1. N/A – Start/end time of restraint was not documented on the progress note for resident #3.
2. 7 additional charts reviewed on 10.24.23 confirmed start/end times of restraints were documented.
3. Retraining of the facility's procedure for restraints in the area of progress notes will occur with all Program Supervisors/Treatment Managers regarding requirement to document start/end time of all restraints on the progress note will occur on 11.6.23. Staff will sign off in acknowledgement of the training and the acknowledgement will be filed in the employee's personnel file.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure start/end times are documented on the progress note and will submit a copy of the progress note to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Program Director for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Program Administrator. For any deficiencies identified during Quality Department's second level review, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 restraints ordered by a licensed practitioner contact the resident's treatment team physician for notification of that restraint as soon as possible for two of six sample resident who were restrained. This practice is specific to Residents #3 and #6.
Findings included:
A review of the records for Resident #3, and #6 was completed on 10/02/2023 approximately 9:30 AM to 11:30 PM, and revealed the following:
Resident #3
A review of the record for Resident #3 revealed that on 08/11/2023 he was placed in a "Seated Floor - 2 Person" restraint (no start and end time noted on this restraint). A review of the record for resident #3 revealed that there is no documented evidence that the treatment team physician was informed of this emergency safety intervention.
Resident #6
A review of the record for Resident #6 revealed that on 09/03/2023 he had the emergency intervention of a upper arm escort implemented by staff from 7:45 PM until 7:47 PM for a duration of 2 minutes. A review of the record for resident #6 revealed that there is no documented evidence that the treatment team physician was informed of this emergency safety intervention.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately
10:40 AM confirmed that there was no documented evidence that the ordering practitioner notified the treatment team physician as soon as possible.
Plan of Correction:1. N/A – Consultation with treatment team physician could not be confirmed for residents 3 and 6.
2. 6 additional charts reviewed on 10.24.23 confirmed notifications of restraints were made to treating physician.
3. Following receipt of order for restraint, if ordering physician is not the assigned treating physician, the nursing department will notify the treating physician of restraint either by phone or email within 24 hours. The nursing department will then obtain the treating physician's signature either in person or through docu-sign within 72 hours of the restraint. A retraining of the nursing department will occur on 11.2.23.
4. The nurse manager (or designee) will conduct a first level review within 24 hours for each order to ensure notification is made to the treating physician if different from the ordering physician and will submit a copy of the Physician's Order to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Director of Nursing for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Nursing Director. For any deficiencies identified during Quality Department's second level review, Nursing Director will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
483.360(b) ELEMENT
CONSULTATION WITH TREATMENT TEAM PHYSICIAN
Name - Component - 00
The person ordering the use of restraint or seclusion must-
483.360(b) Document in the resident's record the date and time the team physician was consulted.
Observations:
Based on a review of facility documents, and interview with administrative staff, the facility failed to ensure that physicians or other licensed practitioners who order restraint, but are not the resident's treatment team physician, contact and consult with the treatment team physician as soon as possible, and document in the resident's record the date and time of this consultation, for one of six sample Residents who have been restrained. This practice is specific to Resident #4.
Findings include:
A review of Resident #4's record of restraint completed on 10/02/2023 between 9:30 AM and 11:30 AM indicated that on 09/18/2023 at 6:08 PM, a restraint was ordered for Resident #4, by a licensed practitioner. The resident record of restraint indicates that the treatment team physician was informed of this physical restraint by the nurse, however there is no date or time documented of when the treatment team physician was consulted.
Interview with the Quality Improvement Coordinator on 10/02/2023, at approximately
11:40 AM confirmed that the date and time of the treatment team physician consultation was not documented.
Plan of Correction:1. N/A – Time of notification to order physician was not documented for resident #4.
2. 7 additional charts were reviewed on 10.24.23 and confirmed ordering physician was the same as treating physician.
3. Following receipt of order for restraint, if ordering physician is not the assigned treating physician, nursing department will notify the treating physician either via phone or email of restraint and
will obtain the treating physician's signature within 72 hours either in person or through docu-sign. A retaining of the nursing department will occur on 11.2.23.
4. The nurse manager will conduct a first level review within 24 hours for each order to ensure notification is made to the treating physician if different from the ordering physician and will submit a copy of the Physician's Order to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Director of Nursing for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Nursing Director. For any deficiencies identified during Quality Department's second level review, Nursing Director will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, 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 well-being of the resident. This practice is specific to
Resident #4.
Findings include:
A review of the record of Resident #4 completed on 10/02/2023 between 9:30 AM and 11:30 AM revealed that he had been restrained on 09/18/2023 at 6:08 PM for a duration of 7 minutes. This incident of restraint was documented on an a form titled Restraint Progress Note. A review of the client debriefing form, for the above mentioned restraint, notes that the face to face client debriefing of this restraint did not occur until 09/28/2023 at 7:30 PM, beyond the 24 hour time frame.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately
11:40 AM confirmed that the client debriefing, for the above mentioned restraint, was not conducted within the 24 hours.
Plan of Correction:1. N/A – Client debriefing was not completed within 24 hours for resident #4.
2. 6 additional records were reviewed on 10.24.23 and confirmed client debriefings were completed within 24 hours
3. Program Supervisors/Treatment Managers were initially trained on requirements of the facility's procedure for restraints in the area of client/staff debriefings on 7.28.23 to include requirement of client/staff debriefings to occur no later than 24 hours after the use of the physical restraint. When the individual declines to participate staff will make at least three (3) separate attempts to engage the individual and document those attempts on the debriefing form. Retraining occurred on 10.6.23 with follow up training scheduled for 11.6.23. Staff will sign off in acknowledgement of the training and the acknowledgement will be filed in the employee's personnel file.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure client/staff debriefings have occurred and will submit a copy of the progress note to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Program Director for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Program Administrator. For any deficiencies identified during Quality Department's second level review, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, staff involved in an emergency safety intervention and appropriate supervisory and administrative staff, conducted a debriefing session that includes a review and discussion of the emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention. This practice is specific to Resident #4.
Findings include:
A review of the record of Resident #4 completed on 10/02/2023 between 9:30 AM and 11:30 AM revealed that he had been restrained on 09/18/2023 at 6:08 PM for a duration of 7 minutes. This incident of restraint was documented on an a form titled Restraint Progress Note. A review of the staff supervisor/s and PA trainer debriefing debriefing form, for the above mentioned restraint, notes that this staff/supervisor debriefing of this restraint did not occur until 09/28/2023 at 4:30 PM, beyond the 24 hour time frame.
Interview with the Quality Improvement Coordinator on 10/02/2023 at approximately 11:40 AM confirmed that the staff/supervisor debriefing, for the above mentioned restraint, was not conducted within the 24 hours.
Plan of Correction:1. N/A – Staff/supervisor debriefing was not completed within 24 hours for resident #4.
2. 6 additional records were reviewed on 10.24.23 and confirmed staff/supervisor debriefings were completed within 24 hours.
3. Program Supervisors/Treatment Managers were initially trained on requirements of the facility's procedure for restraints in the area of staff/supervisor debriefings on 7.28.23 to include requirement of staff/supervisor debriefings to occur no later than 24 hours after the use of the physical restraint. Re-training occurred on 10.9.23 with follow up training scheduled for 11.6.23.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure staff/supervisor debriefings have occurred and will submit a copy of the progress note to the Quality Improvement Department for secondary review within 48 hours. Quality Department will complete a second level review within 72 hours and provide written feedback to the Program Director for follow up for any deficiencies identified during the secondary audit process. Audit process to begin 11.6.23.
5. Oversight by Program Administrator. For any deficiencies identified during Quality Department's second level review, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
483.374(b) ELEMENT
FACILITY REPORTING
Name - Component - 00
Reporting of serious occurrences.
The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State designated Protection and Advocacy system.
Serious occurrences that must be reported include;
- a resident's death;
- a serious injury to a resident as defined in section §483.352 of this part; and
- a resident's suicide attempt.
(1) Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include
- the name of the resident involved in the serious occurrence,
- a description of the occurrence and,
- the name, street address, and telephone number of the facility.
Observations:
Based on review of resident records and interview with the administrative staff, the facility failed to report serious occurances of residents to the state designated protection and advocacy system for one of one sample Resident reviewed who experienced serious occurrence as documented by the facility. This practice is specific to Resident #8.
Findings include:
A review of the facility's incident reports and resident records completed on 10/03/2023 between 9:00 AM and 10:00 AM, revealed the following;
On 09/12/2023 at 2:54 PM, Resident #8 reported to nursing that he was playing basketball with a peer and ran into the peer while chasing after the ball. This resulted in him hurting his foot. Nursing assessed Resident #8's right great toe and noted swelling, bruising and limited movement due to pain. Resident #8 was transported to the local urgent care and was diagnosed with a closed non displaced fracture of the proximal phalanx of right great toe.
A review of Resident #8's record did not reveal any evidence that the State Medicaid agency and Pennsylvania protection and advocacy system (Disabilities Rights Network) had been notified of this serious occurrence.
Interview with the Quality Improvement Coordinator on 10/03/2023 at approximately 9:15 AM, revealed that the facility did not notify the State Medicaid agency and the Disabilities Rights Network of the above mentioned incidents of serious occurances.
Plan of Correction:1. N/A – Notification of serious injury was not reported in the State reporting database The Home and Community Services Information System (HCSIS) and not reported to Disability Rights Network.
2. Review of all additional incidents for month of July-September 2023 was completed on 10.23.24 and did not identify any additional incidents meeting reporting requirements.
3. The Program Director (or designee) will monitor incident reports by reviewing reports in the Devereux electronic incident reporting system and ensure incidents related to serious occurrences are entered into The Home and Community Services Information System (HCSIS) database within 24 hours. Program Director will include HCSIS # in the electronic incident report to confirm reporting has occurred. Staff will sign off in acknowledgement of the training and the acknowledgement will be filed in the employee's personnel file.
4. Quality Department will review all incident reports on a daily basis during regular business hours to ensure compliance with program entries into the State Database and will report any deficiencies to the Director of Quality Improvement. Quality Department will also ensure reports meeting reportable to DRN are submitted.
5. Oversight by Director of Quality Improvement. For any deficiencies identified during Quality Department's review of incidents related to serious occurrences, Director of Quality Department will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 review of staff training records, the facility failed to require ongoing education, trainig and demonstarted knowledge and staff certification in the use of cardiopulmonary resuscitation (CPR), including periodic recertification is required.. This practice was specific to two (2) of 25 sample staff training records which were reviewed.
Findings include:
A review of 25 sample employee training records regarding certification in cardiopulmonary resuscitation (CPR) was completed on 10/03/2023, from approximately 10:30 AM to
11:30 AM. This review revealed thate valid certification status for two (2) of these sample employees had expired.
Interview with the Quality Improvement Coordinator on 10/03/2023 at approximately
11:40 AM, confirmed the CPR certification for the two (2) employees noted above had expired.
Plan of Correction:1. N/A
2. N/A
3. Training department will inform staff and supervisors in writing on a monthly basis of training due, coming due, and overdue. Staff with expired certifications will be placed on administrative leave effective the date of the certification expiration and will not be permitted to work until completion of certification training. Staff who allow their certifications to expire will receive corrective action for failure to maintain compliance with training following the Facility's progressive discipline procedure.
4. Training department will provide monthly updates of required trainings to staff and supervisors. Updates are provided via email and sent out to all staff and supervisors.
5. Oversight by Program Administrator. For any deficiencies identified, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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 record review and interview with administrative staff, the facility failed to ensure that staff demonstrate their competencies in safe use of restraints on a semiannual basis.
This practice is specific to three (3) of 25 staff persons working with the residents of this facility.
Findings include:
A review of the agency's Safe and Positive Approaches (ESI-emergency safety interventions) training for the time period of 05/2022 through 10/03/2023 was completed on 10/03/2023 from approximately 10:30 AM to 11:30 AM. A review of 25 facility staff persons training records noted that 3 of the 25 staff reviewed had not completed a semi-annual demonstration in the safe use of restraints.
Interview with the Quality Improvement Coordinator on 10/03/2022 at approximately
11:40 AM confirmed that three facility staff persons had not completed the emergency safety invention training on a semi annual basis.
Plan of Correction:1. N/A
2. N/A
3. Training department will inform staff and supervisors in writing on a monthly basis of training due, coming due, and overdue. Staff with expired certifications will be placed on administrative leave effective the date of the certification expiration and will not be permitted to work until completion of certification training. Staff who allow their certifications to expire will receive corrective action for failure to maintain compliance with training following the Facility's progressive discipline procedure.
4. Training department will provide monthly updates of required trainings to staff and supervisors. Updates are provided via email and sent out to all staff and supervisors.
5. Oversight by Program Administrator. For any deficiencies identified, Program Administrator will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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