Initial Comments:
A validation survey was conducted February 6-8, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. There were no deficiencies identified.
Plan of Correction:
Initial Comments:
A validation survey was conducted February 6-8, 2023, 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 13 and the sample consisted of six individuals. One deficiency was identified.
Plan of Correction:
483.356(b) ELEMENT
PROTECTION OF RESIDENTS
Name - Component - 00
Emergency safety intervention. An emergency safety intervention must be performed in a manner that is safe, proportionate, and appropriate to the severity of the behavior, and the resident's chronological and developmental age; size; gender; physical, medical, and psychiatric condition; and personal history (including any history of physical or sexual abuse).
Observations:
Based on record review and staff interview, it was determined that the facility failed to develop a plan to ensure safe and appropriate implementation of emergency safety interventions which addressed identified medical concerns. This was noted for one of the two individuals in the sample who had a medical condition (Individual #1). The findings included:
A) The record of Individual #1 was reviewed on February 6-7, 2023. The review revealed a Restrictive Procedure Plan which was developed upon admission to the facility on October 24, 2022. "History of developmental spinal fracture at eight years old; chronic back pain" was documented in the section entitled "Attention to medical concerns when using ESPI" [emergency safety physical intervention]. There was no further documentation in the plan of how this medical condition would be addressed during an ESPI.
Further review of this individual's record revealed that no emergency safety physical interventions (restraints) were performed since admission to the facility.
B) The vice president of quality and risk management (VP of QRM) was interviewed on February 7, 2023 at 12:45 PM. The VP of QRM confirmed that Individual #1's restrictive procedure plan identified the medical condition of past spinal fracture and chronic back pain. In addition, the VP of QRM acknowledged that the plan did not identify how this medical condition would be safely addressed during a restraint.
Plan of Correction:The Psychotherapist for Member 1 updated the Restrictive Procedure Plan by 1/30/23 to reflect the steps to take to ensure safety for this member given their medical diagnosis, which was not presented to the surveyors when they were onsite. On 12/2/22, training was provided by the Vice President of Clinical and Residential Programs to the Director of Admissions and the Director of Clinical Programs regarding completing the Restrictive Procedure Plan correctly. On 12/8/22 and 1/27/23, the Psychotherapists were provided training by the Director of Clinical Programs regarding completing the Restrictive Procedure Plan correctly. This training included that the Psychotherapists send a draft version of the updated Restrictive Procedure Plan for any youth that have a medical condition to the Vice President of Medical Services to review before implementation. Beginning 1/30/23, all current youth in care will have their Restrictive Procedure Plan converted to the new version of the Restrictive Procedure plan. A deadline was set that by 2/22/23, all current youth in care (who will have been admitted prior to 1/9/23) will have their Restrictive Procedure Plan reviewed and updated if there is medical information or procedures to follow for medical concerns. Once all the Restrictive Procedure Plans have been updated for the current youth in care, the MHW Supervisors will train all the direct care staff working in the residence on which Restrictive Procedure Plans have changed as a result of medical concerns. This training will be completed by 3/3/23 and submitted to the Vice President of Clinical and Residential Programs to track to ensure completion. The Vice President of Clinical and Residential Programs will check the most recent ITP, beginning 2/13/23-3/13/23 to ensure that the Restrictive Procedure Plan has been updated so that it can be implemented. The Vice President of Clinical and Residential Programs will keep a spreadsheet and will check the Restrictive Procedure Plans of any new admissions that are admitted after 2/13/23 to ensure correct completion. This practice will occur from 2/13/23-8/13/23. In addition, any future reports of serious occurrences will be scanned and sent to the Vice President of Clinical and Residential Programs, who will monitor the deficient practice until 4/24/23 to ensure that the Restrictive Procedure Plans are reflective of the serious occurrences. If additional deficient practice continues, then additional training will occur after first occurrence. Additional deficient practice after that may result in further disciplinary action.
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