Initial Comments:
An initial validation survey visit was conducted on November 13 and 14, 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 ABH Pennsylvania Children's Services Inc. Villa Upper 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 November 13 and 14, 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 15, and the sample consisted of
six residents.
Plan of Correction:
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 #1 and #3.
Findings include:
Resident #1:
A review of Resident #1's record on 11/13/2023 from approximately 10:00 AM until 12:00 PM revealed that this resident was restrained on 10/28/2023 at 8:22 AM until 8:22 AM (less than 1 minute). 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 #1 was not assessed by a nurse on 10/28/2023 until 4:30 PM, approximately 8 hours post the initiation of the restraint.
Resident #3
A review of Resident #3's record on 11/13/2023 from approximately 10:00 AM until 12:00 PM revealed that this resident was restrained on 09/30/2023 at 5:04 PM until 5:20 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 09/30/2023, however there is no time documented to indicate this assessment occurred within the one hour time frame.
Interview with the Quality Improvement Coordinator on 11/13/2023 at approximately
11:00 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 1 and 3.
2. 2 additional charts reviewed on 11.30.23 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 occurred 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 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.
483.358(h)(5) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Documentation must include] the name of staff involved in the emergency safety intervention.
Observations:
Based on record review and interview with administrative staff, the facility failed to document the names of all staff involved in the emergency safety interventions. This practice is specific to Resident #3.
Findings included:
Resident #3
A review of Resident #3's record on 11/13/2023 from approximately 10:00 AM until 12:00 PM revealed that this resident was restrained on 09/30/2023 at 5:04 PM until 5:20 PM. This restraint was documented on a form titled "Restraint Progress note". Further review of this packet revealed that there are no staff identified to indicate their involvement in this restraint.
Interview with the Quality Improvement Coordinator on 11/13/2023 at approximately
11:00 AM confirmed that staff involved in this restraint were not documented.
Plan of Correction:1. N/A – Staff were not identified to indicate their involvement in the restraint for Resident 3.
2. 2 additional charts reviewed on 11.30.23 confirmed all staff identified as involved in the emergency safety interventions were documented in the Restraint Progress Note.
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 indicate all staff that that are identified as being involved in the restraint on the progress note occurred on 11.14.23. 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 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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