Initial Comments:
An validation survey visit was conducted on March 20 through March 22, 2024. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
The Children's Home of Reading Youth and Family Services Inc. Neag facility is in compliance with the requirements of 42 CFR, Part 441.184, Subpart D Emergency Preparedness regulations for Medicare and Medicaid participating providers and suppliers.
Plan of Correction:
Initial Comments:
An validation survey visit was conducted on March 20 through March 22, 2024. The purpose of this visit was to determine compliance with the requirements of 42 CFR, Part 483, Subpart G regulations for Psychiatric Residential Treatment Facilities for children under age 21. The census at the time of the visit was 35, and the sample consisted of eight residents.
Plan of Correction:
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 record review and interview with administrative staff, the facility failed to ensure orders for restraints were ordered by a physician or other licensed practitioner permitted by the State and the facility for three of eight sample Residents who were restrained.
This practice is specific to Residents #2, #5 and #8.
Findings included:
A review of the records for Residents #2, #5 and #8 was completed on 03/20/2024 from approximately 10:00 AM to 12:30 PM and 03/21/2024 from approximately 9:30 AM to 12:00 PM. This review revealed the Individual #2, #5 and #8 were placed in restraints without a Physician's order for the type of restraints that were utilized.
Individual #2
A review of the record for Resident #2 revealed that he was restrained on 02/12/2024. This restraint was noted on a document titled, "RIR Restrict Intervention" form. This report indicates that Resident #2 was restrained using a "Rear Bear Hug" restraint starting at
11:48 AM for a duration of two minutes. Further review of this Emergency Safety Intervention (ESI) packet revealed a section titled "LP Restraint Order". This section of the ESI packet revealed that the physician/licensed practitioner ordered a standing hold, seated/kneeling hold, and supine hold restraint for this resident. There is no documented evidence that the physician or licensed practitioner ordered the rear bear hug restraint that was utilized during this ESI.
Interview with the Electric Health Record and Quality Specialist on 03/20/2024 at approximately 11:00 AM, confirmed that the Physician and/or Licenced practitioner did not order the rear bear hug for Resident #2 during this ESI.
Individual #5
A review of the record for Resident #5 revealed that he was restrained on 02/10/2024. This restraint was noted on a document titled, "RIR Restrict Intervention" form. This report indicates that Resident #5 was restrained using a "Standing Assist - Extended Arm" restraint starting at 8:52 AM for a duration of less than a minute. Further review of this Emergency Safety Intervention (ESI) packet revealed a section titled "LP Restraint Order". However, there was no content or associated form relevant to this section to include a physician/licensed practitioner (LP) order for this restraint.
Interview with the Electric Health Record and Quality Specialist on 03/21/2024 at 12:00 PM, confirmed that the Physician and/or Licenced practitioner did not order the above restraint for Resident #5 during this ESI.
Resident #8
A review of the record for Resident #8 revealed that he was restrained on 02/12/2024. This restraint was noted on a document titled, "RIR Restrict Intervention" form. This report indicates that Resident #8 was restrained using a "Standing Assist - Upper torso, Standing Assist - Hook transport, and Seated/Kneeling - Upper torso" restraints starting at 5:35 PM for a duration of 15 minutes. Further review of this Emergency Safety Intervention (ESI) packet revealed a section titled "LP Restraint Order". This section of the ESI packet revealed that the physician/licensed practitioner order a standing hold restraint for this resident. There is no documented evidence that the physician or licensed practitioner ordered the Seated/Kneeling -Upper torso restraint that was utilized during this ESI.
Interview with the Electric Health Record and Quality Specialist on 03/21/2024 at 12:00 PM, confirmed that the Physician and/or Licenced practitioner did not order the seated/kneeling - upper torso for Resident #8 during this ESI.
Plan of Correction:1.How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
The agency is not able to go back and alter any documentation. The orders did not match the Safe Crisis Management holds utilized as noted by DOH. All team meeting occurred on 4/3/2024 to address this topic and to educate for each shift. Medical department held a meeting on 4/5/2024 to review the data and retrain. Electronic health record team updated the order documentation listing the statement- the youth is medically cleared for and then lists all the restraints potentially able to be utilized. The nursing assessment will then capture the identified restraints utilized.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
The Licensed practitioner or physician mark the restraints that the youth may have utilized to maintain their safety. A training occurred with the medical team on this change on 4/5/2024. In addition to the internal verbal notification, staff starting the RIR service in the electronic health record will also send an alert to the nursing/medical team.
3. What systematic measures will be put into place to ensure prevention of recurrence?
Staff must communicate on the walkie talkie at the time of the restraint must be communicated. The order will now read that all the restraints that are medically approved for the youth. This will aid in correct identification/usage. On the nursing assessment after the restraint the restraints utilized will be indicated. The Electronic Health Record (EHR) was updated to establish automatic notification triggers to nursing via two methods for restraints as a secondary/additional level of notification to the verbal communication required by staff via walkie talkie at the time of restraint. The order/auth will specifically list the restraints utilized.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
Shift supervisor will communicate with nursing on each shift by the end shift to ensure accurate reporting of all restraints. Clinical director will review restraints within 2 business days and ensure there is a proper order for the restraint in file. Quality Improvement Specialist reviews restraint packets for completion, inclusive of the order matching the restraint on a weekly basis.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
Quality department staff will monitor this and document on a spreadsheet to be reviewed with the residential team weekly. Any incomplete documentation will be required within 2 business days after notification.
483.358(f) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident, including but not limited to-
(1) The resident's physical and psychological status;
(2) The resident's behavior;
(3) The appropriateness of the intervention measures; and
(4) Any complications resulting from the intervention.
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that within one hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions (ESI) and permitted by the state and the facility to assess the physical and psychological well-being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the Resident. This practice is specific to Residents #1, #5, and #7.
Findings included:
A review of the records of Resident #1, #5, and #7 was completed on 03/20/2024 from approximately 9:30 AM to 12:00 PM. This review noted that a face to face assessment of physical and psychological well-being of the resident was not conducted within one hour after the restraint for three of eight Residents that where restrained. Resident #5 and #7 are exemplary of that practice:
Resident #5:
A review of Resident #5's record revealed that this resident was restrained on 02/10/2024 at 8:52 AM to 8:52 AM. This restraint was documented on a form titled RIR Restrict Intervention form. In further review of this ESI packet, the section titled "Passive Restraint Assessment" where the 1 hour post restraint assessment is documented, was missing for this restraint. There was no documented evidence that a physician or other licensed practitioner conducted a face to face assessment of physical and psychological well-being of Resident #5 within one hour after the use of a restraint.
Interview with the Electronic Health Record and Quality Specialist on 03/21/2024 at
12:10 PM revealed that the one hour assessment was not completed for the use of this restraint.
Resident #7
A review of Resident #7's record revealed that this resident was restrained on 03/09/2024 at 7:00 PM to 7:05 PM. This restraint was documented on a form titled "RIR Restrict Intervention". Further review of this ESI packet revealed a section titled "Passive Restraint Assessment". This section noted that the face to face assessment of physical and psychological well-being of Resident #7 was completed at 8:50 PM, one hour and forty-five minutes after the restraint.
Interview with the Electronic Health Record and Quality Specialist on 03/20/2024 at
11:15 AM confirmed that this debriefing was not conducted within one hours post discontinuation of the restraint.
Plan of Correction:1. How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
Staff cannot go back and complete documentation that is out of date and time requirements. All team meeting occurred on 4/3/2024 to address this topic and to educate for each shift. Medical department held a meeting on 4/5/2024 to review the data and retrain. Electronic health record team updated the order documentation listing the statement- the youth is medically cleared for and then lists all the restraints potentially able to be utilized. The nursing assessment will then capture the identified restraints utilized. The electronic health records system in addition to the communication via walkie talkie by staff will also send an alert to the nursing/medical team.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
The Electronic Health Record (EHR) was updated to establish automatic notification triggers to nursing via two methods for restraints as a secondary/additional level of notification to the verbal communication required by staff via walkie talkie at the time of restraint. The shift Supervisor will review with the nursing staff all restraints to ensure notification was received. Nursing will complete the assessment within an hour of the restraint and document in the electronic health record. The Clinical Director reviews the restraint documentation within 2 business days. The quality department is reviewing for completed documentation on each business day and sends out notification to the residential leadership a spreadsheet indicating the status of documentation.
3. What systematic measures will be put into place to ensure prevention of recurrence?
Staff must communicate on the walkie talkie or call at the start of the restraint to communicate immediately. Nursing will then receive a trigger for the required documentation (in the electronic health record system) and conduct a face to face assessment of the physical ad psychological well being of the resident within an hour of the restraint. Shift supervisors will communicate with the medical department to ensure proper and timely communication occurred after restraints. Should a youth refuse assessment, nursing will present to their respective location and conduct observations and document the youth's refusal.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
Shift supervisor will communicate with nursing throughout each shift to ensure accurate reporting and completion of assessments. Nursing manager will review the completion of nursing assessments during the shift or the next business day. Clinical director will review restraints every 2 business days and ensure assessment was completed. Quality Improvement Specialist reviews restraint packets for completion, inclusive of the nursing assessment being completed within the 1 hour timeframe.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
Quality department staff will review and alert residential leadership through the use of a spreadsheet to demonstrate compliance.
483.358(h)(5) ELEMENT
ORDERS FOR USE OF RESTRAINT OR SECLUSION
Name - Component - 00
[Documentation must include] the name of staff involved in the emergency safety intervention.
Observations:
Based on a review of facility documents and interview with administrative staff, the facility failed to ensure that the names of all staff involved in the emergency safety intervention (ESI)were documented for three of eight sample Individuals who were restrained. This practice is specific to Residents #1, #5 and #8.
Findings include:
A review of Resident #1, #5 and #8's records was completed on 03/20/2024 from approximately 10:00 AM to 12:00 PM and on 03/21/2024 from 9:30 AM to 12:30 PM. This review revealed that documentation of restraints utilized did not include the names of all staff who participated in this restrain procedure. Resident #1 and #5 are exemplary of this practice:
Resident #1
A review of Resident 's #1's record revealed that this resident was restrained on 10/02/2023 at 3:54 PM to 3:55 PM, utilizing a "Standing Assist-Extended Arm Escort". This restraint was documented on a form titled "RIR Restrict Intervention". Further review of this "RIR Restrict Intervention" packet revealed that there were no staff names documented to indicate staff who were involved in this restraint.
Resident #5
A review of Resident 's #5's record revealed that this resident was restrained on 03/18/2024 at 8:35 PM to 8:56 PM, utilizing a "Standing Assist-Upper torso, Seated/Kneeling-Upper torso, and Floor Assist-Multiple Person Supine torso with assistance on the legs" restraints. This restraint was documented on a form titled "RIR Restrict Intervention". Further review of this "RIR Restrict Intervention" packet revealed that there were no staff names documented to indicate staff who were involved in this restraint.
Interview with the Director of Quality and Compliance on 03/20/2024 at approximately
10:05 AM confirmed that the above mentioned ESIs did not document the names of all staff involved in the restraint.
Plan of Correction:1. How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
Milieu meetings occur weekly as well as added ongoing support from the on-the-job trainer. Staff will be/were re-trained by 5/12/2024 date regarding appropriate documentation and necessity of staff name inclusion.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
The Electronic Health Record (EHR) restraint packet service was updated to have "required fields" for staff when completing restraint documentation. This change will not allow staff to complete/submit or proceed with documentation until staff names are listed.
3. What systematic measures will be put into place to ensure prevention of recurrence?
Documentation of the staff names is mandatory in the Credible electronic health record system. Staff cannot complete/submit this form unless the data has been added.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
The EHR change implemented that does not allow staff to proceed with documentation until staff names are listed will occur every time a staff member completes a restraint service. Clinical director will review restraints every 48 hours and complete administrative review. Quality Improvement Specialist reviews restraint packets for completion on a weekly basis.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
As noted there are several layers of review and monitoring. The Quality department staff will be the final review and submit to the residential leadership, a spreadsheet demonstrating compliance.
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 #1, #5, #7, and #8.
Findings include:
A review of the records for Residents #1, #5, #7, and #8, completed on 03/20/2024 from 10:00 AM until 12:30 PM and on 03/21/2024 from 9:30 AM until 12:00 PM, revealed that not all staff involved in the invention participated in the face to face discussion, except when the presence of a particular staff person may jeopardize the wellbeing of the resident. Resident #5, #7 and # 8 are exemplary of this practice:
Resident #5
A review of the records of Resident #5 revealed that he had been restrained on 02/28/2024 at 2:59 PM for a duration of 17 minutes. This incident of restraint was documented on an a form titled "RIR Restrict Intervention" packet. A review of the client debriefing form, which is included in this "RIR Restrict Intervention" packet, revealed that this client debriefing was conducted on 02/28/2024 at 3:30 PM and two of the four staff, identified as being involved in this restraint, were not present at this client debriefing. There was no indiction that their presence would jeopardize the wellbeing of this resident.
Resident #7
A review of the records of Resident #7 revealed that he had been restrained on 02/10/2024 at 6:40 PM for a duration of 11 minutes. This incident of restraint was documented on an a form titled "RIR Restrict Intervention" packet. A review of the client debriefing form, which is included in this "RIR Restrict Intervention" packet, revealed that this client debriefing was conducted on 02/10/2024 at 9:00 PM and one of the three staff, identified as being involved in this restraint, were not present at this client debriefing. There is no indiction that their presence would jeopardize the wellbeing of this resident.
Resident #8
A review of the records of Resident #8 revealed that he had been restrained on 02/12/2024 at 8:14 PM for a duration of 2 minutes. This incident of restraint was documented on an a form titled "RIR Restrict Intervention" packet. A review of the client debriefing form, which is included in this "RIR Restrict Intervention" packet, revealed that this client debriefing was conducted on 02/12/2024 at 10:40 PM and one of the two staff, identified as being involved in this restraint, were not present at this client debriefing. There is no indiction that their presence would jeopardize the wellbeing of this resident.
Interview with the Electronic Health Record and Quality Specialist on 03/20/2024 at 11:20 AM and 03/21/2024 at approximately 11:45 AM confirmed that the client debriefing, for the above mentioned restraint, did not include all staff involved in the restraint and there is no indication that the staff's participation would jeopardize the wellbeing of the residents identified.
Plan of Correction:1. How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
Training will occur in the milieu meetings and the on the job trainer will support staff in ensuring all staff that are able to participate in the client debriefing do so within 24 hours. If staff cannot participate due to extenuating circumstances this will be documented. 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.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
If there a discussion does not occur then both the resident and staff will not have 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.
3. What systematic measures will be put into place to ensure prevention of recurrence?
Shift/milieu supervisor will review the restraints at the end of each shift to ensure proper documentation of the debriefing with all staff in attendance and if they are not to explain why they are not present.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
Shift/milieu supervisor will monitor the restraint documentation to ensure this occurs within 24 hours. The Clinical Director will also monitor the documentation and alert if this is not complete. The Quality.EHR Specialist will also monitor and send out any missing parts to the milieu supervisor to complete the documentation.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
The quality department staff will monitor for completion.
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, staff involved in an emergency safety intervention (ESI) and appropriate supervisory and administrative staff, conducted a debriefing session that includes a review and discussion of the emergency safety situation that required the intervention, including discussion of the precipitating factors that led up to the intervention. This practice is specific to Residents #1, #5, #7, and #8.
Findings include:
A review of the records for Residents #1, #5, #7, and #8, was completed on 03/20/2024 from 10:00 AM until 12:30 PM and on 03/21/2024 from 9:30 AM until 12:00 PM. This review revealed that not all staff involved in an emergency safety intervention and appropriate supervisory and administrative staff, conducted a debriefing session that includes a review and discussion of the emergency safety situation that required the intervention. Residents #5 and #7 are exemplary of this practice:
Resident #5
A review of the record of Resident #5 revealed that he had been restrained on 12/03/2023 at 6:33 PM for a duration of 22 minutes. This incident of restraint was documented on an a form titled "RIR Restrict Intervention" packet. A review of the staff debriefing summary revealed that this staff/supervisor debriefing occurred on 12/04/2024 at 4:00 PM and noted that four of seven staff involved in this ESI were not present at this staff/supervisor debriefing. There is no indication as to why they were not in attendance.
Resident #7
A review of the records of Resident #7 revealed that he had been restrained on 02/10/2024 at 6:40 PM for a duration of 11 minutes. This incident of restraint was documented on an a form titled "RIR Restrict Intervention" packet. A review of the staff/supervisor debriefing form, which is included in this "RIR Restrict Intervention" packet, revealed that this staff/supervisor debriefing was conducted on 02/10/2024 at 8:30 PM and one of the three staff, identified as being involved in this restraint, was not present at this staff/supervisor debriefing. There is no indication as to why they are not in attendance.
Interview with the Electronic Health Record and Quality Specialist on 03/21/2024 at approximately 11:45 AM confirmed that not all staff involed in the restraint participated in the staff/supervisor debriefings of the above mentioned ESIs.
Plan of Correction:1. How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
The agency is not able to go back and alter any documentation. Not all staff participated in debriefings as noted by DOH. Review of debriefing expectations occurred in all staff meeting and milieu team meetings.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
Shift/milieu supervisor will communicate to the team to conduct the staff debriefing in order promote a discussion to help foster potential identification to prevent restraints by identifying the precipitating factors to reduce future restraints as possible.
3. What systematic measures will be put into place to ensure prevention of recurrence?
Shift/milieu supervisor will monitor the restraint documentation to ensure staff debriefing occurs prior to the end of the shift and is inclusive of all staff that were involved. If staff cannot attend for extenuating circumstances this will be documented. The Clinical Director will also monitor the documentation and alert if this is not complete. The Quality.EHR Specialist will also monitor and alert the milieu supervisor to complete the documentation if it is incomplete. If staff fail to complete job tasks then discipline of staff will occur.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
Several layers of review will be completed by staff as noted in #3.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
The quality department staff will have the final review of the process and alert the residential leadership of compliance.
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 review of resident records and interview with the administrative staff, the facility failed to report a serious occurrence to both the State Medicaid agency and the state designated protection and advocacy system, for one of one sample Individual who engaged in an attempted suicidal -physical act. This practice is specific to Resident #6.
Findings include:
A review of the facility's incident reports, and resident records completed on 03/21/2024 between 9:00 AM and 10:00 AM. This review revealed the following serious occurrence;
On 12/31/2024 at 4:52 PM, the facility documented, on a form titled "RTR/APHP incident report" and identified the nature of this incident as a suicidal-physical act. The facility described the incident as followed; Resident #6's roommate reported to staff his roommate [Resident #6] was lying on the floor in his room. Staff entered [Resident #6's] room and discovered [Resident #6] had wrapped his hoodie around his neck. Resident #6 cried and asked to be left alone. When unwrapping the hoodie, a string was also found tied around the neck of [Resident #6]. Staff untied the string and [Resident #6] was taken to the nurse to be assessed. The nursing assessment revealed slight bruising on neck and was given Tylenol and sent back to the unit.
Further review revealed that there was no documented evidence that the State Medicaid and State designated Protection and Advocacy system was notified of this serious occurrence of a suicide attempt.
Interview with the Electric Health Record and Quality Specialist on 03/22/2024 at approximately 8:40 AM, confirmed that facility did not report this serious occurrence to either the State Medicaid agency and the state designated protection and advocacy system.
Plan of Correction:1.How the corrective actions will be accomplished for those Individuals identified in the deficiency statements.
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. The on call and residential supervisors were trained in completion of The Home and Community Services Information System (HCSis) reports by the HCSis administrator on 4/2/2024. Reporting requirements were reviewed to be within 24 hours of the incident. The Director of Quality is supporting the training efforts by the residential leadership.
2. How other Individuals will be identified having potential to be affected by the deficient practice.
When staff complete the HCSis it is to be attached to the electronic health record incident service with the fax verifying transmission of the HCSis report. As part of the review by the EHR.Quality specialist of incident and restraints, they will monitor for the attachment and alert the staff of the missing document. The quality and compliance department conducts quarterly audits of records and will additionally monitor for missing documentation.
3. What systematic measures will be put into place to ensure prevention of recurrence?
The shift/milieu supervisor will alert the oncall supervisor of all serious incidents as soon as possible. The oncall supervisor will work with the team to gather all data regarding the incident and complete the HCSIS report and other required reporting. The Quality.EHR Specialist will monitor the client record to ensure staff have completed the required reporting through the HCSis system within 24 hours. The program's administrative assistant will fax and attach the fax proof to the service in the electronic health record.
4. How your facility will monitor its corrective actions to ensure correction and what structure will be put into place to monitor the corrective measures and the continued effectiveness of systematic changes.
The Quality EHR will monitor and send out reports to the program staff alerting to missing notifications weekly. The Director of Quality will check HCSIS for completion/finalization of reports weekly.
5. Identify by position, who will be responsible for such monitoring and what format and/or tools will be completed/retained to measure/substantiate such corrections.
The quality department staff will be the final reviewer of the completion of this task.
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