Initial Comments:
A validation survey visit was conducted on August 16 and 17, 2022. The purpose of this visit was to determine compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations.
The Children's Home of Reading Youth and Family Services, Inc. Cottage facility is in compliance with the Requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness Regulations. There were no deficiencies.
Plan of Correction:
Initial Comments:
A validation survey visit was conducted on August 16 and 17, 2022. The purpose of this visit was to determine compliance with the Requirements of 42 CFR, Part 483, Subpart G Requlations for Psychiatric Residential Treatment Facilities for residents under the age of 21. The census at the time of the visit was twelve, and the sample consisted of six residents.
Plan of Correction:
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 a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, 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 well-being of the resident. This practice is specific to
Residents #2 and #3.
Findings include:
A review of two of four sample Resident restraint records noted that the resident debriefings inconsistently occurred within the 24 hours after the restraint and that all staff involved in the restraint attended the debriefing, except when their presence may jeopardize the well-being of the resident. These include the following:
1. A review of the electronic restraint record of Resident #2 completed on 08/17/2022 between 9:00 AM and 1:00 PM from March 1, 2022 to August 16, 2022 revealed the following;
-On 03/14/2022, Resident #2 was restrained at 5:30 PM for a duration of 2 minutes. This restraint was documented on an electronic restraint incident report. Under the section of this electronic form titled "Client Debriefing", this area was blank.
-On 03/24/2022, Resident #2 was restrained at 3:39 PM for a duration of 6 minutes. This restraint was documented on an electronic restraint incident report. Under the section of this electronic form titled "Client Debriefing" revealed that the client debriefing occurred on 03/26/2022, 2 days post-restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
-On 05/27/2022, Resident #2 was restrained at 7:39 PM for a duration of 15 minutes. This restraint was documented on an electronic restraint incident report. Under the section of this electronic form titled "Client Debriefing" revealed that the debriefing was conducted on 06/09/2022, 13 days post-restraint. Additionally, there was no listing of the staff participating in this debriefing to indicate that all staff involved in the restraint were present.
-06/07/2022, Resident #2 was restrained at 8:25 PM for a duration of 2 minutes. This restraint was documented on an electronic restraint incident report. Under the section of this electronic form titled "Client Debriefing", this area was blank.
2. A review of the record of Resident #3 completed on 08/17/2022 between 9:00 AM and 10:00 AM revealed that this resident had been restrained on 08/07/2022 at 11:10 AM for a duration of 1 minute. This restraint was documented on an electronic restraint incident report. Under the section of this electronic form titled "Client Debriefing" revealed that the client debriefing occurred on 08/10/2022, 3 days post-restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
3. Interview with the quality improvement specialist on 08/17/2022 at approximately 12:30 PM confirmed that the above mentioned restraints the Residents confirmed that The debriefings for the above residents were not conducted within the 24 hour time frame., and on certain instances, all staff did not participate. Additionally, this interviewee confirmed that the lack of documented information on the form under the heading debriefing was indicative that a debriefing meeting was not conducted
Plan of Correction:1.How corrective actions will be accomplished for those individuals identified in deficiency statements:
Residential leadership has developed a checklist for use by the shift supervisor as a method to ensure all required documentation from the shift occurs. If a client declines to engage in a debriefing following a restraint, this form will indicate the need for a 2nd debriefing to be offered within 24 hours of the restraint. The supervisor on the next shift will read the report and complete any outstanding debriefings. Supervisory staff will be trained on all shifts to complete the checklist by 9/15/2022 with use of the form to begin on 9/15/2022 in the 1st shift. A binder will be maintained in the unit staff office for easy access.
The Clinical Director will ensure an administrative review of the restraint within 24hours and will monitor for completion of client debriefings. The electronic health record system has been updated to mandate the section listing who was in attendance and if a staff is missing there must be an explanation documented on the form.
2.How the facility will identify other individuals having the potential to be affected by the same deficient practice:
Leadership has identified this checklist to be used on all units throughout the residential program to ensure client debriefings are occurring in the expected timeline of 24 hours with a 2nd offer for debriefing if the client declines the 1st offered debriefing.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur:
Residential leadership has developed a checklist for use by the shift supervisor as a method to ensure all required documentation from the shift occurs. If a client declines to engage in a debriefing following a restraint, this form will indicate the need for a 2nd debriefing to be offered within 24 hours of the restraint. The supervisor on the next shift will read the report and complete any outstanding debriefings. Supervisory staff will be trained on all shifts to complete the checklist by 9/15/2022 with use of the form to begin on 9/15/2022 in the 1st shift.
The Clinical Director will ensure an administrative review of the restraint within 24hours and will monitor for completion of client debriefings. The electronic health record system has been updated to mandate the section listing who was in attendance and if a staff is missing there must be an explanation.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The checklist is completed by the supervisor on shift to review for all completed documentation. The supervisor on the next shift will read the report and complete any outstanding debriefings. Documentation of this training will be captured in the staff's training record through the RELIAS tracking system. The Clinical Director will ensure an administrative review of the restraint within 24hours and will monitor for completion of client debriefings. Additionally, the Quality and Compliance department will monitor restraint documentation and report to program leadership if there are any noted incomplete services.
5. Identify by position, who will be responsible for monitoring the corrective actions:
Clinical Director, Director of Program Operations, Staff Resource Coordinator, Milieu Supervisor, Senior Youth Behavioral Specialist, EHR/Quality Specialist, Director of Quality and Compliance
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 a review of facility documents and interview with administrative staff, the facility failed to ensure that within 24 hours after the use of restraint, all staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a debriefing session to discuss the precipitating factors that lead up to the intervention. This practice is specific to Resident #3 and #4.
Findings include:
A review of the records for Resident #3 and #4 was completed on 08/17/2022, between 9:00 AM and 11:00 AM for the period of March 1, 2022 through August 16, 2022 and revealed the following:
Resident #3:
Resident #3 was restrained on 08/07/2022. This incident was documented on an electronic restraint incident report (RIR) which documents all aspects of an ESI. The RIR packet indicates that the restraint was initiated at 11:10 AM and discontinued at 11:11 AM. The staff/administration/supervisory debriefing listed all the staff involved in the ESI. However the debriefing occurred on 08/16/2022, 9 days post the use of the restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
Resident #4:
Resident #4 was restrained on 08/13/2022. This incident was documented on an electronic restraint incident report (RIR) which documents all aspects of an ESI. The RIR packet indicates that the restraint was initiated at 7:51 PM and discontinued at 7:54 PM. The staff/administration/supervisory debriefing listed all the staff involved in the ESI. However the debriefing occurred on 08/15/2022, 2 days post the use of this restraint. There was no explanation noted on the debriefing form as to why the meeting was delayed.
Interview with the quality improvement specialist, on 08/17/2022 at approximately 12:35 PM, confirmed that the above mentioned staff/administration/supervisory debriefings were conducted outside the 24 hour time period.
Plan of Correction:1.How corrective actions will be accomplished for those individuals identified in deficiency statements:
Residential leadership has developed a checklist for use by the shift supervisor as a method to ensure all required documentation from the shift occurs. The supervisor on the next shift will read the report and complete any outstanding staff debriefings. Supervisory staff will be trained on all shifts to complete the checklist by 9/15/2022 with use of the form to begin on 9/15/2022 in the 1st shift. Documentation of the training will be housed in the RELIAS training tracking system
The Clinical Director will ensure an administrative review of the restraint within 24 hours and will monitor for completion of staff debriefings. The electronic health record system has been updated to mandate the section listing who was in attendance and if a staff is missing there must be an explanation documented on the form.
2.How the facility will identify other individuals having the potential to be affected by the same deficient practice:
Leadership has identified this checklist to be used on all units throughout the residential program to ensure staff debriefings are occurring after the restraint in the shift.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur:
Leadership has developed a checklist for use by the shift supervisor as a method to ensure all required documentation from the shift occurs. The supervisor on the next shift will read the report and complete any outstanding staff debriefings. Supervisory staff will be trained on all shifts to complete the checklist by 9/15/2022 with use of the form to begin on 9/15/2022 in the 1st shift.
The Clinical Director will ensure an administrative review of the restraint within 24 hours and will monitor for completion of staff debriefings. The electronic health record system has been updated to mandate the section listing who was in attendance and if a staff is missing there must be an explanation.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The checklist is completed by the supervisor on shift to review for all completed documentation. The Director of Program Operations and Staff Resource coordinator will monitor the completion of the checklists throughout the week. Milieu supervisors assigned to the floor will also review and monitor the checklist for completion. The Clinical Director will ensure an administrative review of the restraint within 24 hours and will monitor for completion of staff debriefings. Additionally, the Quality and Compliance department will monitor restraint documentation and report to program leadership if there are any noted incomplete services.
5. Identify by position, who will be responsible for monitoring the corrective actions:
Clinical Director, Director of Program Operations, Staff Resource Coordinator, Milieu Supervisor, Senior Youth Behavioral Specialist, EHR/Quality Specialist, Director of Quality and Compliance.
483.376(b) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Certification in the use of cardiopulmonary resuscitation, including periodic recertification, is required.
Observations:
Based on review of staff training records and interview with the facility training specialist,
the facility failed to require staff certification in the use of in the use of cardiopulmonary resuscitation, including periodic recertification as required. This practice was specific to
1 of 15 employee records which were reviewed.
Findings include:
A review of 15 sample employee training records was completed on 08/17/2022, from approximately 10:30 AM to 1:00 PM. This review revealed that of the 15 records reviewed
one employee who is a registered nurse,did not have evidence that this employee has current certification in CPR
Interview with the Training Specialist on 08/17/2022 at approximately 1:00 PM confirmed there was no CPR certification on record for the one employee, a registered nurse, noted above.
Plan of Correction:1.How corrective actions will be accomplished for those individuals identified in deficiency statements:
The CPR training has been assigned to staff as required. CHOR YFS has hired as of 8/22/2022, a Staff Development Director who will be working with the agency to ensure all staff are current in their CPR training through review of staff files. This position is in addition to the training specialist at the agency. Additional staff at CHOR YFS have been identified to participate in CPR/1st aid trainer certification on 9/28/2022 to ensure adequate training opportunities are afforded to staff. The trainers should be certified as trainers by the end of September 2022. All training records are being reviewed to ensure compliance with CPR.
2.How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The staff development department staff are reviewing all staff compliance with assigned trainings quarterly and identifying any staff nearing their due date to participate in CPR. The staff and their supervisor are alerted as to any upcoming trainings required. Should staff not participate in their required training then Progressive discipline and/or termination can be utilized if the staff is not compliant with scheduling of the training.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur:
The staff development department has a tracking system RELIAS to alert staff and their supervisor of upcoming required trainings prior to their expiration date. Progressive discipline and/or termination can be utilized if the staff is not compliant with scheduling. Additional staff have received the training outside of the staff development department to provide additional training opportunities as needed.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
Training reports will be run quarterly to review through the tracking system Relias in addition to the automatic alerts sent to the staff for upcoming due trainings. A new Staff Development Director was hired to provide oversight on the compliance.
5. Identify by position, who will be responsible for monitoring the corrective actions:
Staff Development Specialist, Staff Development Director, Senior Director of Quality and Compliance, Clinical Director, Director of Program Operations, Staff Resource Coordinator, Milieu Supervisor
483.376(f) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis.
Observations:
Based on a review of facility documentation and staff training records,and interview with the facility training specialist, the facility failed to ensure that staff demonstrate their competencies in the use of emergency safety inventions on a semi annual basis. This practice is specific to three of 10 staff training records that were reviewed.
Findings include:
A review of the facility documentation regarding staff training for emergency safety interventions for the period of 07/2021 through 08/2022, was completed on 08/17/2022, at approximately 10:00 AM. This review indicated that although 3 of the staff reviewed
had completed annual training on the competencies in the use of emergency safety interventions, there was no evidence that these staff had demonstrated these competencies on a semi-annual basis.
Interview with the Training Specialist on 08/17/2022 at approximately 1:00 PM confirmed that three staff persons had not completed a semi-annual demonstration of competency on the use of emergency safety interventions.
Plan of Correction:1.How corrective actions will be accomplished for those individuals identified in deficiency statements:
SCM trainings have been scheduled to ensure all staff comply with Safe Crisis Management training intervals. CHOR YFS has hired as of 8/22/2022, a Staff Development Director who will be working with the agency to ensure all staff are current in their Safe Crisis Management training through review of staff files. This position is in addition to the training specialist at the agency. Additional staff at CHOR YFS have been identified to participate in Safe Crisis Management trainer certification to ensure adequate training opportunities are afforded to staff. The trainers should be certified as trainers by the end of October 2022. All training records are being reviewed to ensure compliance.
2.How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The staff development department staff are reviewing all staff compliance with assigned Safe Crisis Management (SCM) trainings. The staff and their supervisor are alerted as to any upcoming trainings required. Should staff not participate in their required training then Progressive discipline and/or termination can be utilized if the staff is not compliant with scheduling of the training.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur:
The staff development department has a tracking system (RELIAS) to alert staff and their supervisor of upcoming required trainings prior to their expiration date. Additional staff have received the training outside of the staff development department to provide additional training opportunities as needed. Progressive discipline and/or termination can be utilized if the staff is not compliant with scheduling.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
Training reports will be run quarterly to review through the tracking system Relias in addition to the automatic alerts sent to the staff for upcoming due trainings. A new Staff Development Director was hired to provide oversight on the compliance.
5. Identify by position, who will be responsible for monitoring the corrective actions:
Staff Development Specialist, Staff Development Director, Senior Director of Quality and Compliance, Clinical Director, Director of Program Operations, Staff Resource Coordinator, Milieu Supervisor
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