Initial Comments:
A validation survey was conducted November 15-17, 2022, 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 November 15-17, 2022, 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 12 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 two of the six individuals in the sample who had medical conditions (Individuals #1 and #2). The findings included:
A) The record of Individual #1 was reviewed on November 15-16, 2022. The review revealed a Restrictive Procedure Plan which was developed upon admission to the facility on November 22, 2021. "Seizure disorder" 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 11 emergency safety physical interventions (restraints) were performed during the past year. Documentation of these restraints revealed that there were no injuries or mention of seizure activity during or post assessment of Individual #1.
The residential program director (RSD) was interviewed on November 16, 2022, at 9:55 AM. The RSD confirmed that Individual #1's restrictive procedure plan identified the medical condition of seizure disorder. In addition, the RSD acknowledged that the plan did not identify how this medical condition would be safely addressed during a restraint.
B) The record of Individual #2 was reviewed on November 15-16, 2022. The review revealed a Restrictive Procedure Plan which was developed upon admission to the facility on October 3, 2022. "Scoliosis" was documented in the section entitled "Attention to medical concerns when using ESPI". There was no further documentation in the plan of how this medical condition would be addressed during an ESPI.
Further record review revealed that this individual had not been placed in an ESPI since admission.
The RSD was interviewed on November 16, 2022, at 10:00 AM. The RSD confirmed that Individual #2's restrictive procedure plan identified the medical condition of scoliosis. In addition, the RSD acknowledged that the plan did not identify how this medical condition would be safely addressed during a restraint.
Plan of Correction:On 11/25/22, The VP of Clinical and Residential Programs went through all the charts for youth in the PRTF and identified which Restrictive Procedure Plans needed to be modified because of missing plans for medical conditions. Sample Member 1 and Sample Member 2 both had medical conditions noted in their respective Restrictive Procedure Plans with no plan documented in terms of how to manage these medical conditions when these youth are in an ESPI. On 12/2/22, the Vice President of Clinical and Residential Programs confirmed with the Somatic Coordinator that Member 1 and Member 2 do not have medical restrictions in regard to ESPIs that can or cannot be utilized. The Psychotherapists for Member 1 and Member 2 will update the Restrictive Procedure Plan by 12/7/22 to reflect the steps to take to ensure safety during an ESPI for these members given their medical diagnosis. 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, the Psychotherapists were provided additional training by the Director of Clinical Programs regarding completing the Restrictive Procedure Plan correctly. A deadline was set that by 12/23/22, all current youth in care (who will have been admitted prior to 12/2/22) will have their Restrictive Procedure Plan reviewed and updated if there is medical information or procedures to follow for medical concerns. The psychotherapist will email the Director of Clinical Programs and the Vice President of Clinical Programs the document that has been updated so that it can be checked to ensure completion. 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 12/2/22 to ensure correct completion. This practice will occur from 12/2/22-6/2/23. In addition, any future reports of serious occurrences will be scanned and sent to the VP 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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