Initial Comments:
An initial validation survey visit was conducted on December 11 and 12, 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. The Central Office received the required CMS-1513 (January 19, 2024 at 10:33 a.m.); a newly filed d/b/a Devereux Pennsylvania Children's Services (January 18-19, 2024 The PA Department of State, entity number 0013714177); and the JCAHO (January 18, 2024 - Legal Name Change being worked on).
The ABH Pennsylvania Children's Services Inc.Glenloch Left 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 December 11 and 12, 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 four, and the sample consisted of three residents.
The Central Office received the required CMS-1513 (January 19, 2024 at 10:33 a.m.); a newly filed d/b/a Devereux Pennsylvania Children's Services (January 18-19, 2024 The PA Department of State, entity number 0013714177); and the JCAHO (January 18, 2024 - Legal Name Change being worked on).
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 that 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 for one of one sample Resident who was restrained. This practice is specific to Resident #1.
Findings include:
A review of Resident #1's record was completed on 12/11/2023 from approximately
9:30 AM to 11:00 AM. This review revealed Resident #1 was restrained on 11/09/2023.
A review of a document titled, Restraint Progress Note indicated that on that date, the following restraints were employed with this resident as follows:
-Standing-2 arm control- 1 person from 7:19 AM to 7:19 AM;
-Assist to the floor-1 person from 7:19 AM to 7:20 AM;
-Seated floor - 2 person from 7:20 AM to 7:22 AM
-Supine both arms up-3 person from 7:22 AM to 7:28 AM
-Supine-alternating arms -3 person from 7:28 AM to 7:38 AM
Further review of this emergency safety intervention (ESI) packet revealed a document titled "Physician Order/Nursing Assessment dated, 11/9/2023. This document reveals that the physician ordered a "Three person supine" restraint. There was no documented evidence that the physician, or other licensed practitioner permitted by the State had ordered the use of the additional restraints that were implemented during this ESI:
-Standing-2 arm control- 1 person;
-Assist to the floor-1 person;
-Seated floor - 2 person
Interview with the Quality Improvement Coordinator on 12/11/2023, at approximately
11:45 AM, confirmed and acknowledged the the facility failed to obtai
Plan of Correction:1. N/A – Physician's orders for emergency safety interventions for Individual #1 were not obtained for all physical restraints implemented.
2. N/A – There were no additional restraints for review.
3. Program Supervisors/Treatment Managers were trained on 7.28.23, 10.9.23 and 11.6.23 on the facility's procedure for restraints in the areas of documentation and communication of all interventions utilized. On 12.26.23 a campus wide memorandum was submitted to all staff by the Program Administrator attaching the Procedure and highlighting section B – Ordering a physical restraint to "contact the nurse who will communicate with the physician to obtain an order for the restraint utilized."
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 on the interventions utilized. The nurse manager (or designee) will conduct a first level review within 24 hours for each order of restraint to ensure physician's orders are obtained and 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 on any deficiencies identified during the secondary audit process. Audit process began 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 #1.
Findings include:
A review of Resident #1's record was completed on 12/11/2023 between 9:30 AM and 11:00 AM. This review revealed Resident #1 had been restrained on 11/09/2023 at
7:19 AM for a duration of 19 minutes. This incident of restraint was documented on an a form titled Restraint Progress Note. The Resident Progress Note states that three staff were implementing the restraint while there was a nurse observing the restraint until another nurse relieved her so she could complete her medication pass. A review of the client debriefing form for the above mentioned restraint revealed that the debriefing occurred on 11/9/2023 at 2:30 PM, however the two nurses who were observing this restraint that were not in attendance of this debriefing and there was not indication that their presence may jeopardize the wellbeing of the resident.
Interview with the Quality Improvement Coordinator on 12/11/2023 at approximately
11:46 AM confirmed that the client debriefing, failed to include all staff involved in the emergency safety intervention.
Plan of Correction:1. N/A – Staff/individual debriefing did not include all staff involved in the emergency safety intervention.
2. N/A – there were no additional restraints for review
3. Program Supervisors/Treatment Managers were trained on 7.28.23, 10.9.23 and 11.6.23 on the facility's procedure for restraints in the areas of monitoring and debriefs. On 12.26.23 a campus wide memorandum was submitted to all staff by the Program Administrator attaching the Procedure and highlighting sections G – Monitoring during physical restraint and K – Post Restraint Debriefings with expectations any identified Observer is included in the debriefing process.
4. Within 24 hours after the use of a restraint, all staff involved and or identified as an observer, will be involved in the individual/staff debriefing process to review the event and plan for alternative strategies that will reduce the future risk of physical restraints. The Program Director (or designee) will conduct a first level review within 24 hours for each restraint to ensure all staff involved participated in the debriefing process and submit a copy of the Individual/Staff debriefing form 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 on any deficiencies identified during the secondary audit process. Audit process began 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 #1.
Findings include:
A review of Resident #1's record was completed on 12/11/2023 between 9:30 AM and 11:00 AM revealed Resident #1 had been restrained on 11/09/2023 at 7:19 AM for a duration of 19 minutes. This incident of restraint was documented on an a form titled, Restraint Progress Note. The Resident Progress Note states that three staff were implementing the restraint while there was a nurse observing the restraint until another nurse relieved her so she could complete her medication pass. A review of the staff supervisor and PA trainer debriefing form dated 11/09/2023 at 7:45 AM, for the above restraint, revealed that the two nurses who were observing this restraint that were not in attendance of this debriefing and there no indication as to why they were not in attendance.
Interview with the Quality Improvement Coordinator on 12/11/2023 at approximately
11:46 AM confirmed that the staff/supervision debriefing, failed to include all staff involved in the emergency safety intervention.
Plan of Correction:1. N/A – Staff/supervisor debriefing did not include all staff involved in the emergency safety intervention.
2. N/A – there were no additional restraints for review
3. Program Supervisors/Treatment Managers were trained on 7.28.23, 10.9.23 and 11.6.23 on the facility's procedure for restraints in the area of debriefs. On 12.26.23 a campus wide memorandum was submitted to all staff by the Program Administrator attaching the Procedure and highlighting sections G – Monitoring during physical restraint and K – Post Restraint Debriefings with expectations any identified Observer is included in the debriefing process.
4. Within 24 hours after the use of a restraint, all staff involved and or identified as an observer, will be involved in the staff/supervisor debriefing process to review the event and plan for alternative strategies that will reduce the future risk of physical restraints. The Program Director (or designee) will conduct a first level review within 24 hours for each restraint to ensure all staff involved participated in the debriefing process and submit a copy of the Staff/Supervisor Debriefing form 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 on any deficiencies identified during the secondary audit process. Audit process began 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.
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