Initial Comments:
An initial validation survey visit was conducted on March 11 and 12, 2024. 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. Villas Lower 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 March 11 and 12, 2024. 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 eight, and the sample consisted of six residents.
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 #2 and #5.
Findings include:
A review of the records for Resident #2 and Resident #5 was completed on 03/11/2024 from approximately 9:30 AM to 12:00 PM. This review revealed the Individual #2 and #5 were placed in restraints without a Physician's order for the type of restraints that were utilized. Resident #5 is exemplary of this practice:
Individual #5
A review of the record for Resident #5 revealed that he was restrained on 02/03/2024. This restraint was noted on a document titled, "Restraint Progress Note". This report indicates that Resident #5 was restrained using a "Secured escort - 2 person, Assist to Floor - 1 person, Supine - Alternating arms - 3 person and Supine-Both arms up - 3 person " restraints starting at 1:51 PM for a duration of 9 minutes. Further review of the Physician's order/Nursing form of this Emergency Safety Invention (ESI) packet revealed a section titled Emergency Safety Intervention ordered. Under this section for ESI ordered it was blank on this form. There is no indication as to what restraints the physician had ordered.
A review of the record for Resident #5 revealed that he was restrained on 03/05/2024. This restraint was noted on the "Restraint Progress Note". This report indicates that Resident #5 was restrained using a "Assist to Floor - 2 person and a Supine - Alternating Arms - 4 person" ESI, which started at 3:37 PM for a duration of 12 minutes. Further review of this information noted that under the Physician's Order/Nursing Assessment section of this ESI packet revealed that the there was no physician's order for the use of the ""Assist to Floor - 2 person" restraint.
Interview with the Quality Improvement Coordinator on 03/11/2024, at approximately
10:45 AM, confirmed that the facility was unable to verify that a physician's orders were obtained for all restraints used of the above mentioned restraints.
Plan of Correction:1. N/A - Physician's orders for emergency safety interventions for Individuals #2 and 5 were not obtained following incidents of restraints.
2. Remaining two records were reviewed on 3.20.24 and confirmed physician's orders present.
3. Upon the initiation of a restraint, a call will be placed by staff to the nursing department via walkie talkie or phone to alert the nurse of the restraint and requirement for physician's order. Refresher trainings occurred on 3.19.24 and 3.22.24 for Program Supervisors/Treatment Managers and Nursing department respectively to ensure notifications and documentation of physician's orders occur.
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 3.5.24.
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 #5.
Findings include:
A review of Resident #2, #3, #4 and #5's records was completed on 03/11/2024 from approximately 9:30 AM to 12:00 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 #3 and #5 are exemplary of that practice:
Resident #3:
A review of Resident #3's record revealed that this resident was restrained on 12/28/2023 at 8:25 AM to 8:30 AM. 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 12/28/2023 at 9:45 AM, over the one hour time frame.
Continued review of Resident #3's record revealed that this resident was restrained on 01/02/2024 at 3:39 PM to 3:50 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, where the nurse documents the date/time of the assessment, is blank indicating that the face to face assessment was not completed.
Resident #5
A review of Resident #5's record revealed that this resident was restrained on 10/24/2023 at 5:53 PM until 5:53 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 #5 was assessed by a nurse on 10/24/2023 at 7:29 PM, over the one hour time frame.
Interview with the Quality Improvement Coordinator on 03/11/2024 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 5.
2. Remaining two records were reviewed on 3.20.24 and confirmed face-to-face assessments were completed within one hour of initiation of emergency safety intervention.
3. 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. Retraining of nurses of the expectation of one hour face to face assessments was completed on 3.22.24.
4. 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 3.5.24.
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 identify the time the emergency safety intervention actually began and ended for one of six sample Individuals. This practice is specific to Individual #2.
Findings included:
A review of Individual #2's emergency safety intervention records was conducted on 03/11/2024 from 11:00 AM to 11:45 AM. This review revealed an emergency safety intervention was conducted on 03/07/2024. A review of a document titled Restraint Progress Note revealed that Individual #2 was placed in a bear hug as a safety measure after attempting to bang her head against the unit door while trying to force her way out of the unit. After releasing Individual #2 from the bear hug, staff was able to redirect her to her room where she laid on her bed. Further review of this document revealed that the time the emergency safety intervention actually began and ended was not completed on this document.
Interview with the Quality Improvement Coordinator on 03/12/2024 at approximately 10:40 AM confirmed the above information was not included for this emergency safety intervention.
Plan of Correction:1. N/A – Start/end time of restraint was not documented on the progress note for resident #2.
2 Remaining two records were reviewed on 3.20.24 and confirmed start/end times of restraints were documented.
3. Incident report system allows for staff to answer questions on start/end time of restraints which automatically populates into the printed Progress Note as part of the restraint packet. Program Supervisors/Treatment Managers will ensure start/end times are listed on the Progress Note. Retraining of Program Supervisors/Treatment Managers on this expectation occurred on 3.5.24.
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 3.5.24.
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.
483.358(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 a review of facility documents and interview with administrative staff, the facility failed to ensure that the names of all staff involved in the emergency safety intervention (ESI)where documented. This practice is specific to Residents #3 and #5.
Findings include:
A review of Resident #3 and #5's records was completed on 03/11/2024 from approximately 9:30 AM to 12:00 PM. This review noted that not all staff names involved in the ESI were documented.
Resident #3
A review of Resident #3's record revealed that this resident was restrained on 10/26/2023 at 7:58 PM to 8:06 PM, utilizing a "Supine - Alternating Arms - 3 person" restraint. This restraint was documented on a form titled "Restraint Progress note". Further review of this "Restraint Progress Note" revealed that there were only two staff names documented, as being involved in this 3 person ESI restraint.
Resident #5
A review of Resident #5's record revealed that this resident was restrained on 11/09/2023 at 8:25 PM to 8:32 PM, utilizing a "Supine - Alternating Arms - 4 person" restraint. This restraint was documented on a form titled "Restraint Progress note". Further review of this "Restraint Progress Note" revealed that there were only two staff names documented, as being involved in this 4 person ESI restraint.
Interview with the Quality Improvement Coordinator on 03/11/2024 at approximately
11:40 AM confirmed that the above mentioned ESIs did not include the names of all staff involved.
Plan of Correction:1. N/A – Staff were not identified to indicate their involvement in the restraint for Residents 3 and 5.
2. Remaining two records were reviewed on 3.20.24 and confirmed all staff identified as involved in the emergency safety interventions were documented in the Restraint Progress Note.
3. Staff entering incident reports will ensure all staff involved in the emergency safety intervention are identified and documented within the narrative of the Restraint Progress Note. Retraining of this expectation was completed with Program Supervisors/Treatment Managers on 3.5.24.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure all staff involved in the emergency safety intervention are identified and documented within the narrative of the Restraint 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 3.5.24.
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.
483.362(a) STANDARD
MONITORING DURING AND AFTER RESTRAINT
Name - Component - 00
Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention.
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that the clinical staff trained in the use of emergency safety interventions were physically present, continually assessing and monitoring , the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention. This practice is specific to Residents #3 and #5.
Findings include:
A review of Resident #3 and #5's records was completed on 03/11/2024 from approximately 9:30 AM to 12:00 PM. This review noted that clinical staff were not continually assessing and monitoring the physical and psychological well-being and documenting their findings every 5 minutes. Residents #3 is exemplary of that practice:
Resident #3
A review of Resident #3's record revealed that this resident was restrained on 01/02/2024 at 3:39 PM from a duration of 11 minutes. The ESI packet for this occurrence contained a document titled client observation form. This form indicates that staff should be documenting their continual assessment and monitoring of the physical and psychological well-being of the resident and the safe use of restraint every 5 minutes. A review of this form revealed that there was only one 5 minute assessment documented at 3:50 PM for this 11 minute restraint.
Interview with the Quality Improvement Coordinator on 03/11/2024 at approximately
11:45 AM confirmed that staff did not document the 5 minute continual assessment and monitoring of the physical and psychological well-being of the resident and the safe use of restraint for this 11 minute restraint.
Plan of Correction:1. N/A – Staff were not identified to indicate their involvement in the restraint for Residents 3 and 5.
2 Remaining two records were reviewed on 3.20.24 and reviewed on 3.20.24 confirmed all staff identified as involved in the emergency safety interventions were documented in the Restraint Progress Note.
3. Staff trained in the use of emergency safety interventions will document assessment of resident for both physical and psychological well being, every five (5) minutes throughout duration of restraint on the Individual Observation form as part of the restraint packet. Staff's signature on the Observation form will serve as evidence to support ongoing assessment. Retraining of this requirement occurred with all Program Supervisors/Treatment Managers on 3.5.24.
4. The Program Director (or designee) will conduct a first level review within 24 hours to ensure Individual Observation forms are completed, documenting continual monitoring by staff of individual every 5 minutes as applicable 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 3.5.24.
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(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 record review and interview with administrative staff, the facility failed to ensure within 24 hours after the restraint that all staff involved in an emergency safety intervention (ESI) and the resident had a face-to-face discussion, except when the presence of a particular staff person may jeopardize the wellbeing of the resident, and conduct such discussion in a language that is understood by the resident. This practice is specific to Individual #1, #2, #4, and #5.
Findings included:
A review of Resident #1. #2, #3, #4, and #5's records was completed on 03/11/2024 from approximately 9:30 AM to 12:00 PM. This review noted that all staff involved in and ESI were not present at the face to face discussion with the resident and that the face to face discussion was not conducted in the language understood by the resident. Residents #5 is exemplary of that practice:
Resident #5
A review of Resident #5's record revealed that this resident was restrained on 11/11/2023 at 1:13 PM for a duration of 23 minutes, utilizing a "Standing - 2 arm control - 2 person, Assist to the floor - 2 person, Supine - Alternating Arms - 3 person" restraint, and Supine - Alternating arms- 4 person". This restraint was documented on a form titled "Restraint Progress note. Further review of this "Restraint Progress Note" revealed that there were four staff involved in this ESI. Continue review of this ESI packet revealed a Individual debriefing form dated 11/11/2023 and conducted at 1:45 PM. Under the section were it listed all staff involved in the ESI and debriefing there is only one staff listed, as attending this debriefing, out of the four staff involved in this ESI.
A review of Resident #5's record revealed that this resident was restrained on 03/05/2024 at 3:37 PM for a duration of 12 minutes, utilizing a "Assist to the floor - 2 person and Supine - Alternating Arms - 4 person" restraint. A review of the ESI packet revealed a Indvidual debriefing form dated 03/05/2024 and conducted at 4:01 PM. This Resident debriefing form had a statement that was checked off and noted that "Individual is non-verbal and/or in the Moderate to Profound range of intellectual impairment and is unable to provide verbal debriefing responses below". Continued review of this Resident's debriefing revealed that other then the names of staff involved in the ESI, the date and time of this debriefing, the form was blank. There was no indication that the facility attempted to have this face to face discussion in the mode of communication that the Resident utilizes to provide both the resident and the staff an opportunity to analyze the events surrounding the emergency safety situation and intervention.
Interview with the Quality Improvement Coordinator on 03/11/2024 at approximately
11:15 AM confirmed that the above mentioned resident debriefings did not include all staff involved in the ESI and that residents, that are non-verbal, are offered to participate in their ESI debriefing in the language that is understood by the resident.
Plan of Correction:1. N/A – Client debriefing was not completed within 24 hours for resident #5.
2. Remaining two records were reviewed on 3.20.24 and were reviewed on 3.20.24 and confirmed client debriefings were completed within 24 hours
3. Supervisor and/or Safe and Positive Approaches trainers will meet with individual and all staff identified as involved in the physical intervention, within 24 hours for review of incident and identify strategies to prevent reoccurrence. Supervisor and/or Safe and Positive Approaches trainer will document reason staff involved was not present on the Individual/Staff Debriefing form as part of the restraint packet. For individuals who are non-verbal and unable to understand the process, Supervisor and/or Safe and Positive Approaches trainer will notify individual's assigned clinician of restraint for assistance in identifying strategies available and will document notification on the Individual/Staff Debriefing form. Retraining with Program Supervisor/Treatment Manager occurred on 3.5.24.
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 3.5.24.
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 a facility incident report and interview with the administrative staff, the facility failed to report a serious occurrence which resulted in serious injury requiring surgery to both the State Medicaid Agency, and the state designated protection and advocacy system for one of one sample Individual who sustained an injury to the head. This practice is specific to Resident #1.
Findings included:
1. A review of the facility's incident reports, and resident records was completed on 03/11/2024 between 10:15 AM and 10:30 AM. This review revealed the following
information which was documented on the facility incident report as outlined.
- Facility incident report dated 11/30/2023:
[Individual #1] was sitting in the living room participating in the activities at 4:04 PM when she started banging her forehead on the table. [Individual #1] transitioned from school with a big bruise on her forehead while in the unit, [Individual #1] transitioned in the restroom and continued to bang her head on the wall. Staff intervened by putting a pad between her forehead and the wall to prevent further injury to her head. Upon evaluation by the nurse, a recommendation for Individual #1 to be seen at the emergency room for further evaluation.
Upon return from the emergency room, nursing noted the following:
"[Individual #1] reopened her forehead wound, which is blood red and surrounded by a large area of edema. The skin is reddened and starting to bruise purple. She does not show any outward signs of pain. She seems slightly less alert than usual but is awake and calm. PRN sedation was administered and she was sent back to the emergency room with staff for further evaluation. A CAT scan of Individual #1's head without IV contrast was performed and the results were negative for any kind of brain damage."
Further review of the incident report documentation dated 11/30/2023, and subsequent record review noted that there was no indication that the facility had reported this serious injury to either the State Medicaid agency and Pennsylvania protection and advocacy system (Disabilities Rights Network).
Interview with the Quality Improvement Coordinator on 03/11/2024 at approximately 10:30 AM, confirmed that facility did not report this serious occurrence to either the State Medicaid agency and Pennsylvania protection and advocacy system.
.
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 October 2023 - February 2024 was completed on 3.13.24 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. Quality Department will ensure reports meeting reportable are faxed to the Bureau of Program Integrity (BPI) and the Disability Rights Network (DRN).
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 (HCSIS) and will report any deficiencies to the Director of Quality Improvement. Quality Department will also ensure reports meeting reportable are submitted to the Bureau of Program Integrity (BPI) and the Disability Rights Network (DRN). Fax confirmation sheets will be maintained as evidence to support these notifications.
5. Oversight by Director of Quality Improvement. Quality Improvement Manager will notify Director of Quality Improvement of any deficiencies identified during Quality Department's review of incidents related to serious occurrences and notifications to the Bureau of Program Integrity (BPI) Disability Rights Network (DRN), Director of Quality Department will provide supervisory follow up with staff not meeting this requirement up to and including progressive disciplinary actions.
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