Initial Comments:
A validation survey was conducted November 29 through December 2, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. Five deficiencies were cited.
Plan of Correction:
441.184(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to develop an emergency preparedness (EP) plan that was based on and included a documented, facility-based, and community-based risk assessment utilizing an all-hazards approach. The findings included:
A) The facility's EP plan was reviewed on November 29-30, 2021. This review revealed no documentation that an all-hazards facility-based and community-based risk assessment, including but not limited to natural disasters, man-made disasters, and equipment or utility failure, was utilized to develop the EP plan.
B) The associate director (AD) was interviewed on November 30, 2021, between 9:25 AM and 10:20 AM. The AD confirmed that the EP plan did not include a documented, facility-based, and community-based risk assessment utilizing an all-hazards approach in the development of the EP plan.
Plan of Correction:A risk assessment will be completed by and outside auditor that will utilize an all-hazards approach that is facility-based and community-based. The assessment will be completed by 1/15/22. The Associate Director of Residential Programs, The Associate Director of Clinical Services, and The Program Supervisor will be responsible for ensuring the risk assessment is completed and contains the required elements.
The Plan will be reevaluated after each Emergency Drill by Children's Home of York President and CEO, Director of Human Resources, and Director of Finance to ensure that the risk assessment has been completed and that it utilized an all hazards approach that is facility-based and community-based, and that the plan is appropriate for the clients the staff and the facility.
441.184(b)(1) STANDARD
Subsistence Needs for Staff and Patients
Name - Component - 00
§403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1)
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:
(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.
*[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to develop and implement emergency preparedness (EP) policies and procedures to address the provision of subsistence needs for staff and individuals. The findings included:
A) The facility's EP policies and procedures were reviewed on November 29-30, 2021. This review revealed that there was no policy to address the use of alternate sources of energy (i.e., temperature control, emergency lighting, fire detection and alarm systems, and sewage and waste) during an emergency situation.
B) The associate director (AD) was interviewed on November 30, 2021, between 9:25 AM to 10:20 AM. The AD confirmed that there were no facility-specific EP policies or procedures to address the use of alternate sources of energy during an emergency situation.
Plan of Correction:The Associate Director of Clinical Services, The Associate Director of Residential Programs, and the Program Supervisor will develop a policy/procedure to address the need for alternate sources of energy to maintain temperature, lighting, and other amenities by 1/31/22
The Plan will be reevaluated after each Emergency Drill by the Children's Home of York President and CEO, Director of Human Resources, and Director of Finance to ensure that the need for alternate sources of energy to maintain temperature, lighting, and other amenities has been addressed, and that the plan is appropriate for the clients the staff and the facility.
441.184(b)(8) STANDARD
Roles Under a Waiver Declared by Secretary
Name - Component - 00
§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.
*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure their emergency preparedness (EP) policies and procedures addressed the facility's role under a waiver declared by the Secretary, in the provision of care and treatment at an alternate care site identified by emergency management officials. The findings included:
A) The facility's EP plan was reviewed on November 29-30, 2021. This review revealed that there was no policy or procedure to address the role of the facility in providing care and treatment at alternate care sites during an emergency.
B) The associate director (AD) was interviewed on November 30, 2021, between 9:25 AM and 10:20 AM. The AD confirmed that the facility's EP plan did not include policies and procedures to address the facility's role under a waiver declared by the Secretary, in the provision of care and treatment at an alternate care site.
Plan of Correction:The Associate Director of Clinical Services, The Associate Director of Residential Programs, and The Program Supervisor will develop a policy/procedure to address how the facility will provide care and treatment to the residents while at an alternate care site by 1/31/22
The Plan will be reevaluated after each Emergency Drill by the Children's Home of York President and CEO, Director of Human Resources, and Director of Finance to ensure that the facility can provide appropriate care and treatment to the residents while at the alternate care site, and that the plan is appropriate for the clients the staff and the facility.
441.184(c)(7) STANDARD
Information on Occupancy/Needs
Name - Component - 00
§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Based on documentation review and staff interview, it was determined that the facility's emergency preparedness (EP) plan failed to identify a means to provide crucial information to authorities during an emergency. The findings included:
A) The facility's EP communication plan for emergency situations was reviewed on November 29-30, 2021. This review revealed no documentation of the facility's means to communicate the following information to local, state, and federal authorities during an emergency situation:
- the occupancy of the facility
- the need for food, water, and medical supplies
- the assistance needed for evacuation
B) The Associate Director (AD) was interviewed on November 30, 2021, between 9:25 AM and 10:20 AM. The AD confirmed that the facility's EP plan did not identify a means to communicate the needs of the facility to local, state, and federal authorities during an emergency situation.
Plan of Correction:The Associate Director of Clinical Services, The Associate Director of Residential Programs, and The Program Supervisor will develop a policy/procedure to address how the facility will communicate crucial information to authorities during emergency by 1/31/22.
The Plan will be reevaluated after each Emergency Drill by the Children's Home of York President and CEO, Director of Human Resources, and Director of Finance to ensure that the facility can communicate crucial information to authorities during the emergency, and that the plan is appropriate for the clients the staff and the facility.
441.184(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to provide biennial training and competency in the emergency preparedness (EP) plan. This was noted for 12 of the 22 staff training records reviewed. The findings included:
A) The facility's EP training and competency testing was reviewed on December 1, 2021. This review revealed training and competency in the EP plan for 12 staff members was conducted in April 2018. There was no documentation to indicate that these 12 staff members received training and competency testing to date.
B) The training assistant (TA) was interviewed on December 1, 2021, at 11:55 AM. The TA confirmed that the facility failed to conduct training and competency on the emergency preparedness plan to all staff on a biennial basis.
Plan of Correction:A training program will be created by the training department by 2/15/22. This program will include a competency test at the end of the training. All applicable staff will be trained in the new plan by either the Training Department or the Program Supervisor by 2/28/22. All staff must pass the competency test. Any staff member that does not pass the competency test will not be able to work in the program until they have past the test. All staff will be required to retrain on the plan once every calendar year. The training Coordinator will be responsible for tracking and implementing training in each staff member's training file.
Initial Comments:
A validation survey was conducted November 29, through December 2, 2021, 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 seven and the sample consisted of four individuals. Seven deficiencies were cited.
Plan of Correction:
441.156(c) ELEMENT
TEAM DEVELOPING INDIVIDUAL PLAN OF CARE
Name - Component - 00
The team must include, as a minimum, either-
(1) A Board-eligible or Board-certified psychiatrist;
(2) A clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; or
(3) A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases, and a psychologist who has a master's degree in clinical psychology or who has been certified by the State or by the State psychological association.
Observations:
Based on record review and staff interview, it was determined that the facility failed to develop and review a plan of care every 30 days with a team that included the psychiatrist. This was noted for one of the four individuals in the sample (Individual #1). The findings included:
A) Individual #1's record was reviewed on November 30, 2021. The review revealed that this individual was admitted to the facility on June 1, 2021. The initial plan of care (developed on June 1, 2021) was not signed by the psychiatrist.
B) Further record review revealed a 30-day review of Individual #1's plan of care was conducted on October 12, 2021. There was no documentation that this review included the psychiatrist.
C) The associate director of clinical services (ADCS) was interviewed on November 30, 2021, at 9:30 AM. The ADCS confirmed that there was no documentation that the psychiatrist was included in the initial development of Individual #1's plan of care. In addition, the ADCS confirmed that there was no documentation that the psychiatrist was part of the team at the 30-day review of Individual #1's plan of care conducted on October 12, 2021.
Plan of Correction:Mental Health Workers will review all current and past Plans of current clients and have the treating psychiatrist review and sign any plan that has not already been reviewed and signed by 1/15/22.
Upon the completion of the treatment team meeting the Program Coordinator will secure signatures for all team members present. The sign in sheet will be scanned in case the original is misplaced. The original will be placed in the psychiatrist mailbox to be delivered by the Transportation Aid. The Transportation Aid will deliver the paperwork to the psychiatrist for review and signature on a weekly basis. Once the signature is acquired the Transportation Aid will deliver the sign in sheet back to the program. Upon receiving the sign in sheet it will be filed by the Mental Health Worker in charge of filing. Before filing, the Mental Health Worker will ensure that all required signatures are present on the form. If required signatures are not present the Mental Health Worker will inform the Program Coordinator so that the signatures can be obtained within 24 hours. All program staff will be retrained on this regulation and Plan of correction by the Associate Director of Clinical Services by 1/31/22. All Staff will complete a training form upon completion of the training. It will be secured in their training record. The training department will be responsible for retaining the record.
The Continuous Quality Improvement Department will review all Treatment team signature pages on a weekly basis for 6 months to ensure that the psychiatrist attended and signed the paperwork in a timely manner. The findings will be recorded on CQI review forms. These forms will be emailed to the therapist responsible, the Associate Director of Clinical Services, and the Program Coordinator. If it is found that this plan of correction was successful after 6 months, CQI will decrease to monthly reviews for 3 months. If this step is successful the CQI team can return to completing regular quarterly chart reviews and discharge chart reviews to ensure that all paperwork and signatures have been completed. If CQI finds errors during the first 6 months, or the second 3 months the POC will be reevaluated for effectiveness, The signature will be obtained by the Program Coordinator within 24 hours, and appropriate HR actions will be taken with the staff member responsible. If CQI finds errors after the first 6 months The signature will be obtained by the Program Coordinator within 24 hours, and appropriate HR actions will be taken with the staff member responsible.
441.156(d) ELEMENT
TEAM DEVELOPING INDIVIDUAL PLAN OF CARE
Name - Component - 00
The team must also include one of the following:
(1) A psychiatric social worker.
(2) A registered nurse with specialized training or one year's experience in treating mentally ill individuals.
(3) An occupational therapist who is licensed, if required by the State, and who has specialized training or one year of experience in treating mentally ill individuals.
(4) A psychologist who has a master's degree in clinical psychology or who has been certified by the State or by the State psychological association.
Observations:
Based on record review and staff interview, it was determined that the facility failed to develop and review a plan of care every 30 days with a team that included a registered nurse. This was noted for three of the four individuals in the sample (Individuals #1, #2, and #3). The findings included:
A) The records of Individuals #1, #2, and #3 were reviewed November 29-30, 2021. This review revealed that the team who developed and/or conducted 30-day reviews did not include a registered nurse in the following:
Individual #1
Initial plan of care dated June 1, 2021
30-day review dated July 21, 2021
30-day review dated October 12, 2021
Individual #2
Initial plan of care dated April 21, 2021
30-day review dated July 7, 2021
30-day review dated September 1, 2021
Individual #3
30-day review dated May 19, 2021
30-day review dated June 16, 2021
30-day review dated October 6, 2021
B) The associate director of clinical services (ADCS) was interviewed on November 29-30, 2021. The ADCS confirmed that there was no documentation that the registered nurse was part of the team that developed and/or reviewed the plans of care for Individuals #1, #2, and #3.
Plan of Correction:Mental Health workers will review all current and past Plans of current clients and have the Registered Nurse review and sign any plan that has not already been reviewed an signed by 1/15/22.
A Registered Nurse will be scheduled on shift for every treatment team meeting by the Program Supervisor. It will be the responsibility of the RN to attend the meeting and sign the sign in sheet. It will be filed by the Mental Health Worker in charge of filing. Before filing, the Mental Health Worker will ensure that all required signatures are present on the form. If required signatures are not present the Mental Health Worker will inform the Program Coordinator so that the signatures can be obtained within 24 hours. All Program staff will be retrained on this regulation and plan of correction by the Associate Director of Clinical Services by 1/31/22. All Staff will complete a training form upon completion of the training. It will be secured in their training record. The training department will be responsible for retaining the record.
The Continuous Quality Improvement Department will complete quarterly file reviews, as well as file reviews for discharged clients. If a required signature is found to be missing during the Mental Health Worker file review, or the CQI review proper HR actions will be taken to ensure that staff members are following regulations.
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 documentation review and staff interview, it was determined that the facility failed to ensure that physician who ordered restraints was trained in the use of emergency safety interventions. This was noted for the psychiatrist who ordered restraint for two individuals (Individuals #1 and #2). The findings included:
A) Safe Crisis Management (SCM) training records for all of the facility staff was requested on November 30, 2021, to include the psychiatrist. A review of these trainings was conducted on December 1, 2021. There was no documentation that the psychiatrist was trained in the use of emergency safety interventions.
B) The training assistant confirmed on December 1, 2021, at 11:36 AM, that there was no documentation that the psychiatrist was trained in the use of emergency safety interventions.
C) The facility's policy entitled Restrictive Procedures for Residential Services and Programs, revised October 8, 2020, was reviewed on November 29, 2021. This review revealed that "manual physical restraint may only be used when ordered by a physician or other licensed practitioner permitted by the state and facility to order restraint and trained in the use of emergency safety interventions."
Plan of Correction:All Psychiatrists currently contracted to provide care to the clients of Children's Home of York will be required to complete the Safe Crisis Management Online Certification by 1/15/21. Director of Human Resources will ensure that all psychiatrists complete the online course.
The completion date of the the training will be added to the training file for each psychiatrist. Safe Crisis Management must be completed within 365 days of the last certification. The Executive Assistant is in charge of monitoring all contractor certifications. The SCM certification will be added to the Contractor Certification Tracking Check list. The Executive Assistant will monitor that all psychiatrists are trained prior to ordering a restraint. The Executive Assistant monitors the Check list Monthly to make sure that all necessary certifications are up to date. The Executive Leadership Team and the Contractor are notified a month prior to any certification expiring. If a lapse in certification is found, the Executive Leadership Team and the Contractor will be notified and they will not be allowed to prescribe Emergency Safety Interventions until the certification requirement is met. Appropriate HR actions will be taken with any contractor who is non compliant with regulations.
483.362(c) ELEMENT
MONITORING DURING AND AFTER RESTRAINT
Name - Component - 00
A physician, or other licensed practitioner permitted by the state and the facility to evaluate the resident's well-being and trained in the use of emergency safety interventions, must evaluate the resident's well-being immediately after the restraint is removed.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure that individuals were assessed by a physician, or other licensed practitioner permitted by the state, immediately upon release of a restraint. This was noted for the only two individuals in the sample who were restrained in the past year (Individuals #1 and #2). The findings included:
A) The facility's policy entitled Restrictive Procedures for Residential Services and Programs, revised October 8, 2020, was reviewed on November 29, 2021. This review revealed that "a face-to-face assessment of the physical and psychological well-being of the resident must be completed by appropriate personnel immediately upon release from the restraint, or, when this is not possible, within one hour of the initiation of the restraint. Appropriate personnel include a certified registered nurse practitioner, physician assistant, or registered nurse, if a physician is not available."
B) Individual #1's record was reviewed on November 29-30, 2021. This review revealed that this individual was restrained on September 6, 2021, at 8:10 PM. This restraint was released three seconds later. Review of the restraint packet revealed an assessment was conducted by a registered nurse on September 6, 2021, at 9:26 PM. This assessment was performed over one hour after the restraint was released.
C) Individual #2's record was reviewed on November 29-30, 2021. This review revealed that this individual was restrained on September 6, 2021, at 8:10 PM. This restraint was released three seconds later. Review of the restraint packet revealed an assessment was conducted by a registered nurse on September 6, 2021, at 9:26 PM. This assessment was performed over one hour after the restraint was released.
D) The program supervisor (PS) was interviewed on November 29, 2021, at 2:00 PM. The PS confirmed that Individuals #1 and #2 were not assessed by the registered nurse immediately upon release of the restraint. In addition, the PS acknowledged that the policy does not comply with the federal regulations.
Plan of Correction:We are currently in the process of hiring 2 new Registered Nurses to fill the positions where we are currently utilizing Licensed Practical Nurses. The Human Resources Assistant will post open positions on our website and other platforms. Human Resource Director is contracting with a health care staffing agency to fill these positions.
Currently there is an Registered Nurse on call for every shift that there is not a Registered Nurse scheduled in the building. During the current emergency health crisis, until more Registered Nurses can be hired, Mental Health Workers, or Administrative staff will contact the on call Registered Nurse immediately upon a child being placed in a restraint. If it is possible the on call Registered Nurse will be contacted prior to the initiation of the restraint. If they cannot make it to the facility within an hour, once the child has been released and is safe to be transported, a Mental Health Worker, Administrative staff, or Licensed Practical Nurse will transport the child to the nearest emergency room, or urgent care center.
Program and Agency Administrative staff will be retrained on this regulation by the Associate Director of Clinical Services by 1/15/22. The training will be documented in each employees Training file, monitored by the Training Department. Program Administration staff scheduled or on call at the time of the restraint will be responsible for monitoring that the immediate assessment is conducted by appropriate personnel.
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 documentation review and staff interview, it was determined that the facility failed to conduct a face-to-face discussion which included the staff involved in the restraint. This was noted for the only two individuals who were restrained in the past year (Individuals #1 and #2). The findings included:
A) The facility's Restrictive Procedures for Residential Services and Programs policy, revised October 8, 2020, was reviewed on November 29, 2021. Review of this policy revealed that "within 24 hours after the use of the manual physical intervention, two debriefings must occur....The second debriefing should include all team member[s] involved in the intervention with the resident ..."
B) Individual #1's record was reviewed on November 29-30, 2021. This review revealed that this individual was restrained on September 6, 2021, at 8:10 PM. Review of the restraint packet revealed that debriefing documentation did not include all of the staff identified as being involved in the restraint of Individual #1.
C) Individual #2's record was reviewed on November 29-30, 2021. This review revealed that this individual was restrained on September 6, 2021, at 8:10 PM. Review of the restraint packet revealed that debriefing documentation did not include all of the staff identified as being involved in the restraint of Individual #2.
D) The associate director of clinical services (ADCS) was interviewed on November 30, 2021, at 11:50 AM. The ADCS confirmed that the above-mentioned debriefings did not include all the staff identified as being involved in the restraint of Individuals #1 and #2.
Plan of Correction:A new Debriefing with client form will be created by the Associate Director of Clinical Services, and The Program Supervisor by 1/15/22. This form will include a space for all staff members who either performed the restraint, or who witnessed the restraint to record their name. All staff whose names appear on this form must be present for the debriefing with client. The debriefing will occur prior to the end of the shift so that all staff members can be present. It will be the responsibility of the Mental Health Workers on shift as well as the Administrator on call to ensure that if they were involved in the restraint that they are involved in the debriefing. The administrator on call will be informed by the staff member who reports the restraint who was involved. All program staff will be trained on this regulation and plan of correction by the Associate Director of Clinical Services by 1/15/22.
The Director of Human Resources will attend and observe all debriefings with the client for a period of 6 months to ensure that all staff involved are present. When this is seen to be successful the Director of Human Resources will attend every other debriefing with client for a period of 3 months. Once this is seen to be successful the Director of Human Resources will discontinue attending the debriefings. The Program Supervisor and or Associate Director of Clinical Services will monitor and sign off on all debriefing forms to ensure staff member compliance. The Continuous Quality Improvement Department will review all debriefing forms for 6 months to ensure that the staff members have attended and signed. The findings will be recorded on CQI review forms. These forms will be emailed to the Associate Director of Clinical Services, and the Program Supervisor. If it is found that this plan of correction was successful after 6 months, CQI will then review every other debriefing form for a 3 month period. Once this is successful CQI will return to completing regular quarterly chart reviews and discharge chart reviews to ensure that all paperwork and signatures have been completed. If CQI finds errors during the first 6 months or the second 3 months the POC will be reevaluated for effectiveness, and appropriate HR actions will be taken with the staff member responsible. If CQI finds errors after the second 3 months appropriate HR actions will be taken with the staff member responsible.
The Associate Director of Clinical Services will train the Mental Health Workers on this regulation, and how to complete a file review to determine if other clients were affected by this deficiency. This training will be completed by 1/7/22. A file review will be completed by Mental Health Workers to determine if other current clients have been affected by this deficiency by 1/15/22.
483.370(b) ELEMENT
POST INTERVENTION DEBRIEFINGS
Name - Component - 00
Within 24 hours after the use of restraint or seclusion, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session that includes, at a minimum, a review and discussion of -
483.370(b)(1) The emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention;
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to conduct debriefing sessions with the administrative/supervisory staff, that included all the staff involved in the restraint. This was noted for the only two individuals who were restrained in the past year (Individuals #1 and #2). The findings included:
A) The facility's Restrictive Procedures for Residential Services and Programs policy, revised October 8, 2020, was reviewed on November 29, 2021. Review of this policy revealed that "within 24 hours after the use of a manual physical intervention, two debriefings must occur. The firsts[first] of these include all team members involved in the intervention and appropriate supervisory/administrative team members."
B) The records of Individuals #1 and #2 were reviewed on November 29-30, 2021. This review revealed that restraints were utilized with these two individuals on September 6, 2021. Review of the restraint packets for both of these individuals revealed that not all the staff identified as being involved in the restraint were included at the debriefing with the supervisory or administrative staff.
C) The associate director of clinical services (ADCS) was interviewed on November 30, 2021, at 11:52 AM. The ADCS confirmed that the above-mentioned debriefings did not include all of the staff identified as being involved in the restraint of Individuals #1 and #2.
Plan of Correction:The Associate Director of Clinical Services will train the Mental Health Workers on this regulation, and how to complete a file review to determine if other clients were affected by this deficiency. This training will be completed by 1/7/22. A file review will be completed by Mental Health Workers to determine if other current clients have been affected by this deficiency by 1/15/22.
A new Debriefing with supervisor form will be created by the Associate Director of Clinical Services, and The Program Supervisor by 1/15/22. This form will include a space for all staff members who either performed the restraint, or who witnessed the restraint to record their name. All staff whose names appear on this form must be present for the debriefing with supervisor. The debriefing will occur prior to the end of the shift so that all staff members can be present. It will be the responsibility of the Mental Health Workers on shift as well as the Administrator on call to ensure that if they were involved in the restraint that they are involved in the debriefing. The administrator on call will be informed by the staff member who reports the restraint who was involved. All program staff will be trained on this regulation and plan of correction by the Associate Director of Clinical Services by 1/15/22.
The Director of Human Resources will attend and observe all debriefings with the supervisor for a period of 6 months to ensure that all staff involved are present. When this is seen to be successful the Director of Human Resources will attend every other debriefing with supervisor for a period of 3 months. Once this is seen to be successful the Director of Human Resources will discontinue attending the debriefings. The Program Supervisor and or Associate Director of Clinical Services will monitor and sign off on all debriefing forms to ensure staff member compliance. The Continuous Quality Improvement Department will review all debriefing forms for 6 months to ensure that the staff members have attended and signed. The findings will be recorded on CQI review forms. These forms will be emailed to the Associate Director of Clinical Services, and the Program Supervisor. If it is found that this plan of correction was successful after 6 months, CQI will then review every other debriefing form for a 3 month period. Once this is successful CQI will return to completing regular quarterly chart reviews and discharge chart reviews to ensure that all paperwork and signatures have been completed. If CQI finds errors during the first 6 months or the second 3 months the POC will be reevaluated for effectiveness, and appropriate HR actions will be taken with the staff member responsible. If CQI finds errors after the second 3 months appropriate HR actions will be taken with the staff member responsible.
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 ensure all serious occurrences were reported to the State Medicaid Agency (SMA) no later than close of business the next business day after the serious occurrence. This was noted for the only individual who experienced a serious occurrence (Individual #2) in the past year. The findings included:
A) The facility's policy entitled Reportable Incidents Requirements, Revised December 20, 2016, was reviewed on November 29, 2021. This review revealed that "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."
B) A review of facility incident reports was conducted on November 29, 2021. This review revealed that on June 5, 2021, Individual #2 reported that she was having suicidal thoughts while in the bathtub, went under the water and then came back up. The incident report notification page revealed that the SMA was not notified of this serious occurrence until June 10, 2021, five days later.
C) The program supervisor (PS) was interviewed on November 30, 2021, at 2:28 PM. The PS confirmed that this serious occurrence for Individual #2 was not reported to the SMA by the close of business the next business day.
Plan of Correction:When administrative staff is not present in the facility, Incident Reports are completed by the administrative staff on call. These reports are then electronically transmitted to Children's Home of York A.N.G.E.L. Center where a mental health worker will print and fax to the State Medicaid Agency, and other appropriate team members. Administrative staff on call is responsible for ensuring all appropriate entities are notified of serious occurrences by close of business the next business day. Program Supervisor will be responsible for re-training all current staff on reportable incidents, as well as the procedure for reporting. This training will include what constitutes a serious occurrence, what team members need to be notified, and how to notify each team member, and the time frames for reporting occurrences. The training will be completed by 1/31/22. The Administrative staff on call is responsible for ensuring all appropriate entities have been notified. The administrative staff will review incident reports to ensure that all necessary entities have been notified by close of business the next business day from the report. If errors are found, the entity that was not notified will be notified immediately. The offending staff member will be required to be retrained the procedure, and appropriate HR actions will be taken.
|