Initial Comments:
A validation survey was conducted October 17-20, 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 October 17-20, 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 14 and the sample consisted of six individuals. One deficiency was identified.
Plan of Correction:
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 documentation review and staff interview, it was determined that the facility failed to report a serious occurrence to the state Medicaid agency (SMA) by the close of business the next business day. This was noted for the only individual in the sample who attempted to commit suicide (Individual #1).
The findings included:
A) The facility's incident reports for the past year were reviewed on October 17, 2022. This review revealed that on May 30, 2022, Individual #1 had attempted suicide by "taking 10 Ibuprofen [pills] with the intention to kill herself" while on a therapeutic leave. This individual was discharged from the hospital and returned to the facility. There was no evidence that the SMA was notified of this serious occurrence.
B) The facility's policy for "Recordable/Reportable Incident" revised February 23, 2022, was reviewed. This review revealed that "a physical act by a youth/young adult to commit suicide" was a reportable incident.
C) The director of residential services (DRS) was interviewed on October 17, 2022, at 2:25 PM. The DRS confirmed that Individual #1's attempt to commit suicide was not reported to the SMA by the close of business the next business day.
Plan of Correction:On 10/17/22, an email was sent by the VP of Clinical and Residential Programs to all Residential Supervisors reminding them of the expectation that all reporting of serious occurrences needed to be faxed to the state Medicaid agency. On 10/18/22, VP of Clinical and Residential Programs sent out a re-training log to all the Residential Supervisors who would be faxing documentation outside of business hours providing training on the reporting of serious occurrences being faxed to the state Medicaid agency. All Residential Supervisors turned these logs in by 10/24/22. On 10/24/22, an email was sent by the VP of Clinical and Residential Programs to all Residential Supervisors that moving forward, an email is to be sent to the VP of Residential and Clinical Programs informing them that the report of serious occurrence was faxed to the state Medicaid agency. This information was also reviewed with the MHW Supervisors and Program Managers on 10/25/22 during the Supervisor meeting. The Residential Supervisors were sent a coaching log to train them regarding the regulation for reporting serious occurrences to the state Medicaid agency in the regulated timeframe on 10/27/22. 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 they were faxed to the state Medicaid agency. 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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