CMS HSC Inspection

April 13, 2016

CMS - Certification & Enforcement Branch Attn: Helen Jewell 1961 Stout Street, Room 08-148 Denver, CO 80294

DEPARTMENT OF SOCIAL SERVICES HUMAN SERVICES CENTER

POBOX7600 YANKTON, SD 57078-7600

PHONE: 605-668-3100 FAX: 605-668-3460

WEB: dss.sd.gov

RE: Conditions for Participation (CoPs)- SD Human Services Center

Dear Ms. Jewell:

Enclosed is the Addendum Plan of Correction for the South Dakota Human Services Center. This is in regards to the recertification survey conducted at our facility on March 2, 2016 by CMS.

Should you have any questions regarding the plan of correction, please contact Glenn Black, Administrator at 605-668-3102.

Sincerely,

Gif:J.Mtµv Administrator

GJB:ss

Enclosures

APR 14'i611=1iAM

Physical Delivery Address - 3515 Broadway Avenue, Yankton, South Dakota 57078

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER:

434003

(X2) MULTIPLE CONSTRUCTION

A. BUILDING _______ _

B. WING _________ _

Printed: 03/23/2016 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

03/02/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER 3515 BROADWAY AVE POST OFFICE BOX 7600 YANKTON, SD 57078

(X4)1D PREFIX

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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULA TORY

OR LSC IDENTIFYING INFORMATION)

B 000 INITIAL COMMENTS

An unannounced Recertification survey was conducted by Federal consulting surveyors from February 29, 2016 to March 2, 2016. The census at the time of this survey was 91 patients; the sample was eight (8).

B 098 482.60 SPEC PROVISIONS APPL YING TO PSYCH HOSPITALS

The hospital must meet all special provisions applying to psychiatric hospitals.

This Condition is not met as evidenced by: Based on interview and document review, the facility failed to ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons. Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services in a Non-Distinct Part (non-certified) unit to the Distinct Part (certified) Unit and integrated them with the adolescent patients who receive services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the quality treatment of patients receiving psychiatric services. (Refer to 899)

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8000

8098

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

he plan of correction completion and monitoring ill be reported to the HSC governing body. The dministrator of the facility has overall

responsibility for development and implementation of the Poe.

dolescent patients receiving chemical ependency treatment will be transitioned from he certified unit to other community inpatient ettings or discharged with completion of reatment. New admissions to the chemical ependency program were discontinued.

Each patient residing on the certified unit who re receiving chemical dependency treatment ill be assessed by the treatment team.

Referrals and discharge plans to the appropriate evel of care will be made and carried out.

he policy and procedure Patient Unit Relocation will be reviewed and revised. This policy will include a review by the Administrator, Medical Director, Directors of Operations,

linical Services, and Nursing, prior to any unit mbinations to ensure proper licensure for

patients served. All temporary unit closures or ombinations will be reported to the Director of

Health Information and Quality Management.

he Director of Health Information and Quality Management will review the Patient Unit Closure

hecklist to ensure that patients who are housed nd treated in designated units/beds for acute

psychiatric care are receiving services for the iagnosis and treatment of mentally ill persons. he Director of Health Information and Quality

B 099 Management will report the findings of these

(X5) COMPLETION

DATE

B 099 482.60(a) SPEC PROVISIONS APPL YING TO PSYCH HOSPITALS reviews to the Quality Council until the Quality /22/16

Psychiatric hospitals must be primarily engaged in providing, by or under the supervision of a doctor of medicine or osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

ouncil indicates standards are met and reporting is no longer necessary.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused fr correcting proliding it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

(XS) DATE

FORM CMS-2567(02-99) Previous Versions Obsolete UX5311 If continuation sheet Page 1 of 43



(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY


B 000 INITIAL COMMENTS

An unannounced Recertification survey was conducted by Federal consulting surveyors from February 29, 2016 to March 2, 2016. The census at the time of this survey was 91 patients; the sample was eight (8).

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B 000 8098 (continued from page 1) ~ddendum: irhe Director of Health Information and Quality Management will report to Quality Council Monthly, the results of the reviews of Patient Uni1 Closure Checklist. The expectation is 100% compliance with no combining of units with different licensure. Upon 6 months of 100%

(X5) COMPLETION

DATE

B 098 482.60 SPEC PROVISIONS APPL YING TO PSYCH HOSPITALS

B 098 compliance, the Quality Council may indicate ~,,,');(, ~tandards are met and reporting is no longer .

11*1V4

need to be required.

The hospital must meet all special provisions applying to psychiatric hospitals.

This Condition is not met as evidenced by: Based on interview and document review, the facility failed to ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons. Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services in a Non-Distinct Part (non-certified) unit to the Distinct Part (certified) Unit and integrated them with the adolescent patients who receive services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the quality treatment of patients receiving psychiatric services. (Refer to 899)

B 099 482.60(a) SPEC PROVISIONS APPL YING TO PSYCH HOSPITALS

Psychiatric hospitals must be primarily engaged in providing, by or under the supervision of a doctor of medicine or osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

8099

TITLE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

(X6) DATE


IA




434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



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B 099 Continued From page 1

This Standard is not met as evidenced by: Based on interview and document review, the facility failed to ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons. Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services in a Non-Distinct Part (non-certified) unit to the Distinct Part (certified) Unit and integrated them with the adolescent patients who receive services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the quality treatment of patients receiving psychiatric services.

Findings include:

A. On 2/29/16 at 9:45 a.m. the Director of Quality Management reported that adolescent patients receiving treatment for chemical dependency (CD) had been moved from a Non-Distinct Part Unit (P2) to the adolescent Distinct Part Unit (02) due to a low census on both Units. This change was implemented on June 18, 2015.

B. During observation of the 02 Unit and interview with 02 staff members, Program Director 1 and Chemical Dependency Supervisor 2 reported that CD adolescent patients were assigned rooms on the unit halls with the adolescent patients receiving services for psychiatric care, but not as roommates. They reported that the CD patients receive programming treatment separate from the

FORM CMS-2567(02-99) Previous Versions Obsolete

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(X5) COMPLETION

DATE

8099 8099 Adolescent patients receiving chemical dependency treatment will be transitioned from he certified unit to other community inpatient

settings or discharged with completion of reatment. New admissions to the chemical dependency program were discontinued.

Each patient residing on the certified unit eceiving chemical dependency treatment will be

assessed by the treatment team. Referrals and discharge plans to the appropriate level of care will be made and carried out.

[The policy and procedure Patient Unit Relocation will be reviewed and revised. This policy will include a review by the Administrator, Medical Director, Directors of Operations, Clinical Services, and Nursing, prior to any unit ~mbinations to ensure proper licensure for patients served. All temporary unit closures or combinations will be reported to the Director of Health Information and Quality Management.

[The Director of Health Information and Quality Management will review the Patient Unit Closure Checklist to ensure that patients who are housed and treated in designated units/beds for acute psychiatric care are receiving services for the ~iagnosis and treatment of mentally ill persons. [The Director of Health Information and Quality Management will report the findings of these reviews to the Quality Council until the Quality ~ouncil indicates standards are met and reporting is no longer necessary. ~ddendum: 4/22/16 [The Director of Health Information and Quality Management will report to Quality Council Monthly, the results of the reviews of Patient Uni1 Closure Checklist. The expectation is 100% ~ompliance with no combining of units with ~ifferent licensure. Upon 6 months of 100% ~ompliance, the Quality Council may indicate $tandards are met and reporting is no longer need to be required.

UX5311 If continuation sheet Page 2 of 43




434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



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patients receiving psychiatric services, but added that the patients were combined for activities/groups offered on evenings, weekends and holidays. They reported that the CD patients are hospitalized on the 02 unit for 30-90 days.

C. Review of patient census for the first day of the survey (2/29/16) revealed that there were CD patients (H1, HS, H7, HB, H9 and H13) housed on 02 Unit with six (6) patients receiving psychiatric services including active sample Patient H3.

D. Review of documents provided by the Director of Quality Management revealed that an additional 19 adolescent patients had received care and treatment for Chemical Dependency since June 18, 2015.

E. During interview on 2/29/16 at 3:20 p.m., RN4 reported that nursing staff are responsible for the CD adolescent patients except for CD focused formal programming (groups/activities).

B 103 482.61 SPEC MEDICAL RECORD REOS FOR PSYCH HOSPITALS

The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution.

This Condition is not met as evidenced by: Based on observation, interview, and record review, the facility failed to:

1. Ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons.


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B 099 8103 (1.) ~dolescent patients receiving chemical k:lependency treatment will be transitioned from the certified unit to other community inpatient settings or discharged with completion of treatment. New admissions to the chemical k:lependency program were discontinued.

Each patient residing on the certified unit receiving chemical dependency treatment will be assessed by the treatment team. Referrals and k:lischarge plans to the appropriate level of care will be made and carried out.

!fhe policy and procedure Patient Unit Relocation will be reviewed and revised. This policy will include a review by the Administrator, Medical Director, Directors of Operations, Clinical Services, and Nursing, prior to any unit combinations to ensure proper licensure for patients served. All temporary unit closures or combinations will be reported to the Director of Health Information and Quality Management.

rhe Director of Director of Health Information and Quality Management will review the Patient

B 103 Unit Closure Checklist to ensure that patients who are housed and treated in designated units/beds for acute psychiatric care are eceiving services for the diagnosis and

•reatment of mentally ill persons. The Director of Health Information and Quality Management will report the findings of these reviews to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary. Addendum:

(X5) COMPLETION

DATE

The Director of Health Information and Quality Management will report to Quality Council Monthly, the results of the reviews of Patient Uni1 Closure Checklist. The expectation is 100% compliance with no combining of units with different licensure. Upon 6 months of 100% compliance, the Quality Council may indicate 4/22/16 standards are met and reporting is no longer need to be required.





434003



B. WING _________ _


OM8 NO 0938-0391


03/02/2016



(X4)1D PREFIX

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8 103 Continued From page 3

Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services in a Non-Distinct Part (non-certified) unit to the Distinct Part (certified) Unit and integrated them with the adolescent patients who receive services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the quality treatment of patients receiving psychiatric services. (Refer to 899)

II. Provide active individualized psychiatric treatment, including alternative treatment interventions for one (1) of eight (8) active sample patients (87), who was not motivated to attend groups listed on the unit schedule. This patient spent many hours without structured activities spending most of his/her time in his/her bedroom or sitting in the day room. Failure to provide active treatment can result in longer hospitalization and delayed recovery. (Refer to 81251)

Ill. Ensure that patients in one (1) of eight (8) units (C2) were offered treatment modalities on a regularly scheduled basis. There were no structured groups/activities offered on a regular basis for patients housed on the adult wing of Unit C2, including active sample Patient F5. Failure to provide sufficient hours of active treatment prevents patients from achieving their optimal level offunctioning, thereby potentially delaying a timely discharge. (Refer to 812511)

IV. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and

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8 103 8103 (11.) Self-paced worksheets and workbooks with

individual staff review with patient will be provided as alternative treatment options. All patient treatment plans will be reviewed and revised to include options for active treatment based on the patient's assessed strengths, needs, and interests as needed.

The policy "Treatment Plan" will be reviewed and revised to provide for the provision of alternative treatment. Treatment plans of current patients will be reviewed by the unit Charge Nurses to ensure inclusion interventions for providing alternative forms of active treatment as needed.

Education on the options available for active reatment and the policy change will be provided o all staff. Treatment plans of current patients will be reviewed by the unit Charge Nurses to ~nsure inclusion interventions for providing !alternative forms of active treatment.

A unit treatment log will be created to monitor ~reatment participation and the provision of !alternative treatment options for patients who refuse groups or are unable to participate. Education on the options available for active ~reatment, the unit activity log, and the policy ~hange will be provided to all staff.

The Program Directors (2) will review unit !activity logs weekly to ensure the provision of !alternative treatment options to patients. The Program Directors will report the results of the reviews to the Director of Clinical Services for review and corrective action to ensure compliance. The Director of Clinical Services will report the findings to the Quality Council until the KJuality Council indicates standards are met and reporting is no longer necessary. ~ddendum: rT"he Director of Clinical Services will report results of active treatment audits to the Quality Council monthly. The expectation is 90% compliance. Upon 6 months of 100% compliance, the Quality Council may indicate ~tandards are met and reporting to Quality ~ouncil is no longer required.

(XS) COMPLETION

DATE





434003

(X2) MULTIPLE CONSTRUCTION A. BUILDING _______ _

B. WING _________ _


OMB NO 0938-0391


03/02/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE


(X4)1D PREFIX

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B 103 Continued From page4

three (3) of three (3) discharged patients (X 1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to 8125 Ill)

B 116 482.61(b)(6) PSYCHIATRIC EVALUATION

Each patient must receive a psychiatric evaluation that must estimate intellectual functioning, memory functioning and orientation.

This Standard is not met as evidenced by: Based on record review and interview, there was failure to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (81, 87, 05, F1, F5 and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

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B 103 8103 (Ill) A schedule for active treatment groups was

created and implemented on Cedar 2 on 4/13/16. Self-paced treatment options will also be implemented on Cedar 2 for patients that were unable or did not wish to participate in group activities.

A unit treatment log will be created and implemented on Cedar 2 to track patient involvement in group or individual treatment.

Staff education on activity schedule, activity log, ~nd self-paced treatment work will be provided !for all Cedar 2 staff.

Program Directors (2) will review unit activity log weekly to ensure the providing of active lreatment. Findings of these reviews will be provided to the Director of Clinical Services for review and corrective action. The Director of Clinical Services will report the findings to the Quality Council until the Quality Council indicates standards are met and reporting is no onger necessary.

B 116 i'\ddendum:

The Director of Clinical Services will report results of active treatment audits to the Quality Council monthly. The expectation is 100% compliance. Upon 6 months of 100% compliance, the Quality Council may indicate standards are exceeded and reporting to Quality Council is no longer required.

(XS) COMPLETION

DATE





434003


A. BUILDING

B. WING _________ _


OMB NO 0938-0391


03/02/2016



(X4)1D PREFIX

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B 103 Continued From page4

three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to 8125 Ill)





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B 103 8103 IV. The policies related to physical restraints will be eviewed and revised to ensure patient privacy

When physical or mechanical restraints are used. irhe use of the safety frame (transport board) will be discontinued. The safety frame will be removed from policy. Safety hoods will be removed from policy and use will be c1iscontinued. The presence of a staff member on the unit at all times when Cedar 2 is occupied was required effective 3/2/16. The policies related to physical restraints will be revised to add the RN reviewing documentation, assessing patient for earliest release from restraint or seclusion and documenting assessment at least hourly in the medical record. The Physical Restraint/ Chemical Restraint/ Seclusion Monitoring Progress Note was revised to include a nursing assessment of patient behavior at least hourly.

Safety Chairs will be ordered to replace the Safety frames. All staff will be provided education on the use of the Safety Chair and policy change. Defensive protective equipment (face shields and bite protection sleeves) will be ordered. All staff will be provided education on

B 116 he use of the protective equipment and policy change. All staff will be provided re-education on he requirement for earliest possible release 'ram restraint or seclusion by the Human Rights Specialist.

The Human Rights Specialist and the Director of Health Information and Quality Management Will review each episode of the use of restraint or seclusion to ensure compliance. Any concerns Will be reported to the Medical Director and ~dministrator for corrective action. Daily staffing sheets for Cedar 2 will be reviewed weekly by he Nurse Managers (2) to ensure staff presence

on the unit when occupied. Findings of these reviews will be reported to the Director of Nursing or designee weekly for review and corrective action. Each of the responsible parties above will report findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

(XS) COMPLETION

DATE


56

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES



434003


A. BUILDING

B. WING _________ _


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03/02/2016



(X4)1D PREFIX

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B 103 Continued From page4 three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to 8125111)





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B 103 B 103 (IV) continued DON or Designee will report results of staffing audits to Quality Council monthly. Expectation is 90% compliance, with C2 staffed when patients are on the unit. Upon 6 months of 100% compliance, the Quality Council may indicate standards are met and reporting is no longer needed. Director of Health Information and Quality Management will report audits of Seclusion and Restraint Events to ensure elease at earliest time. Expectation is 100%

compliance. Upon 6 months of 100% compliance, Quality Council May indicate standards are met and reporting to Quality

(XS)

COMPLETION DATE

Council is no longer required. Addendum: 4/22/16 The Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of Orientation, memory functioning and/or intellectual functioning in measurable terms to he Quality Council. The expectation is 100% compliance. Upon 6 months of 100 % compliance, the Quality Council may indicate standards are met and reporting to Quality !Council is no longer required.

Addendum B 116 The Director of Health Information and Quality

Management will report audits of Seclusion and Restraint Events and DON or designee will report audits of staffing sheets to the Quality Council monthly.





434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



(X4)1D PREFIX

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B 103 Continued From page 4 three (3) of three (3) discharged patients (X 1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to 8125 Ill)



This Standard is not met as evidenced by: Based on record review and interview, there was failure to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (81, 87, D5, F1, F5 and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

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B 103

8116



A template for completion of psychiatric ~valuations was created to include orientation,

B 116 memory functioning and/or intellectual ,unctioning in measurable, behavioral terms.

The policy "Psychiatric Evaluation" was reviewed to ensure inclusion of orientation, memory functioning and/or intellectual Wunctioning in measurable, behavioral terms.

Education will be provided to all Psychiatry ~taff on the standards for psychiatric evaluation ~nd the template for completion. Education will be provided to all Psychiatry staff ~n the standards for psychiatric evaluation and ~he template for completion. Director of Health Information and Quality Management will review 10% of all psychiatric evaluations each month for inclusion of ~rientation, memory functioning and/or jntellectual functioning in measurable, behavioral ~erms. The Director of HI/QM will report findings weekly to the Medical Director. The Medical Director will meet monthly with Psychiatric Staff

(X5) COMPLETION

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(X4)1D PREFIX

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three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to 8125111)



This Standard is not met as evidenced by: Based on record review and interview, there was failure to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (B 1, 87, 05, F1, F5 and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.


ID PREFIX

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CROSS-REFERENCED TO THEAPPROPRIA TE DEFICIENCY)

(XS) COMPLETION

DATE

B 103 8116 continued

B 116

~o review and continue to educate to ensure compliance. Psychiatric staff performance out of ~mpliance will be referred to Medical Executive ~mmittee and President of Medical Staff for corrective actions.

Addendum: Jhe Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of Orientation, memory functioning and/or "ntellectual functioning in measurable terms to he Quality Council. The expectation is 100%

compliance. Upon 6 months of 100 % compliance, the Quality Council may indicate 4/22/16 standards are met and reporting to Quality Council is no longer required.

Addendum: The Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of Orientation, memory functioning and/or intellectual functioning in measurable terms to he Quality Council monthly.


5e...




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Findings include:

A. Document Review

1. Patient 81: The psychiatric evaluation (2/17 /16) failed to address memory or intellectual functioning.

2. Patient 87: The psychiatric evaluation (2/5/16) failed to address to address orientation, memory or intellectual functioning.

3. Patient 05: The psychiatric evaluation (1/22/16) failed to address orientation, memory or intellectual functioning.

4. Patient F1: The psychiatric evaluation (1/6/16) stated, "Patient does not respond to formal mental status exam." The follow-up progress note (1nt16) documented orientation, but failed to address memory or intellectual functioning.

5. Patient F5: The psychiatric evaluation (2/11/16) failed to address orientation, memory or intellectual functioning.

6. Patient H3: The psychiatric evaluation (9/20/15) failed to give basis for memory assessment. The statement read: "Memory is fairly reliable for history."

8. Interview:

During interview on 3/2/16 at 10:30 a.m., the Medical Director acknowledged the above patient findings. Regarding Patient F5, he reported that it was especially important that the basis for this information be documented as this patient is receiving ECT.

8 117 482.61(b)(7) PSYCHIATRIC EVALUATION

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8 116

8 117



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Each patient must have an individual comprehensive treatment plan.

This Standard is not met as evidenced by: Based on medical record review and interview, treatment plans were developed by a Counselor (Social Service paraprofessional), rather than by the treatment team. This inappropriate delegation of responsibility for patient treatment planning to non-professional unlicensed team members resulted in treatment plans that were not individualized based on individual patient needs.

Findings include:

A. Record Review:

A. Review of treatment plans for eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87 (2/4/2016); 810 (2/16/16); 05 (1/28/16); E10 (dated 12/24/15); F1 (2/29/16); F5 (2/10/16); G2 (dated 12/29/16) and H3 (10/6/15 with unclear review date) revealed that the majority of interventions were assigned to a counselor (unlicensed social work paraprofessional); these interventions included both 1: 1 and group therapies. The treatment plan for one (1) of eight (8) sample patients (F1) assigned the responsibility for the implementation and evaluation of all interventions to the counselor, including nursing safety interventions. All interventions for one (1) of eight (8) sample patients (F5) were assigned to a counselor or an activity therapist.

B. Interview

1. During interview on 3/1/16 at 11 :00 a.m. and review of active Patient D5's treatment plan,


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8118 8118 !The treatment plan format was revised to reflect the creation of the treatment plan by licensed members of the treatment team.

!The policy ''Treatment Plan" will be reviewed and revised to define the treatment team members responsible for the creation of the treatment plan ~s professional staff in the disciplines of Psychiatry, Nursing, Social Work, Occupational rJ"herapy, Physical Therapy, Dietetics, and Speech Therapy. The Class Specification for the position Human Services Counselor will be reviewed and revised. The development of patient treatment plan will be removed from the iob function.

Education on the new treatment plan format and l:>olicy revision will be provided to all staff.

rrhe Nurse Managers (2) will review 1 0% of all patient treatment plans to ensure the treatment plans were created and developed by professional members of the treatment team as defined in policy. Nurse Managers will report the findings of these reviews to the Director of Nursing or designee weekly for review and corrective actions. The DON or designee will report the results of these findings to the Quality Council until the Quality Council indicates $tandards are met and reporting is no longer necessary.

Addendum: lfhe DON or designee will report the results of ~he treatment plan audits to the Quality Council monthly. The expectation is 100% compliance With treatment plans created and developed by 4/22/16 professional members. Upon six months of 100%, the Quality Council may indicate $tandards are met and reporting to Quality Council is no longer required.





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Counselor 7 reported that he developed the treatment plans and submitted these "treatment plans during patient rounds." When discussing repetition of the RN interventions, Counselor 7 stated, ''You'll find the same ones."

2. During interview with review of treatment plans on 3/2/16 at 11 :00 a.m., the Director of Clinical Services and the Director of Social Work acknowledged that some of the treatment interventions that should have been assigned to professional staff were assigned to the counselors (unlicensed paraprofessionals).

C. Review of the Class Specification (9/06) for the Human Services Counselor revealed the following statements:

1. "The Human Services Counselor develops treatment plans and conducts individual and group counseling sessions for patients who have mental health needs."

2. "Reviews case histories, biographies, and other data pertaining to patients in order to determine problems, their causes and possible remedies."

3. "Develops and implements appropriate therapeutic treatment modalities for patients across the lifespan."

B 122 482.61(c)(1)(iii) TREATMENT PLAN

The written plan must include the specific treatment modalities utilized.

This Standard is not met as evidenced by: Based on record review and interview, the facility failed to develop treatment plans that clearly

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B 122



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8122 Continued From page 9

delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87 (2/4/2016); 810 (2/16/16); 05 (1/28/16); E10 (dated 12/24/15); F1 (2/29/16); F5 (2/10/16); G2 ( dated 12/29/16) and H3 ( 1 0/6/15 with unclear review date). Instead most of the interventions for these professionals were routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Treatment Plan Review:

1. Patient 87

For the problem "Hallucinations" Patient 87, MTP there was no listed interventions for physicians or nursing.

2. Patient 810

For the problem "Psychosis" Patient 810 MTP interventions stated: a. "Psychiatrist will prescribe and monitor medications for illness" frequency and duration of this generic intervention was not included. b. "RN will provide medication education" the frequency and duration of the intervention was not included.

3. Patient 05

a. For problem, "recent self-harm attempts," there were no nursing interventions to guide staff in the


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8122 8122 The treatment plan format for all patient .reatment plans will be changed to clearly indicate the involvement of professional staff. The new format allows for individualization specific to patient needs and strengths.

Education will be provided to all professional staff on treatment planning, the individualization of treatment plans, and the roles of professional staff in the treatment planning process.

The Nurse Managers (2) will review 10% of all patient treatment plans to ensure proper delineation of interventions for professional staff. Nurse Managers will report the findings of these eviews to the Director of Nursing or designee

weekly for review and corrective actions. The DON or designee will report the results of these 'indings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary. 4/22/16

Addendum:

The DON or designee will report the results of reatment plan audits to the Quality Council

monthly. The expectation is 100% compliance with treatment plans defined proper delineation of interventions for professional staff. Upon six months of 100%, the Quality Council may "ndicate standards are met and reporting to Quality Council is no longer required.





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care of this patient in the clinical area.

b. For problem, "assaulting staff and destroying property at [his/her] last placement," there were no nursing interventions to guide staff in the care of this patient in the clinical area when patient was showing assaultive behavior. The only nursing interventions were role functions listed as "Nurse will provide education re: benefits, side effects and risks" and "Nurse will administer medications and monitor for effectiveness and side effects." The same nursing intervention, "Nurse will administer medications and monitor for effectiveness and side effects" was again listed for another goal under the same problem.

Another generic nursing intervention listed for this problem was, "Nurse will provide pharmacy pamphlets and education on prescribed medication and diagnosis."

c. For problem, "discharge/aftercare plan," generic social work interventions were listed as "SW (Social Work) will keep informed of patient's treatment progress and needs by weekly attendance at treatment team meetings." "SW will meet with patient at least monthly to discuss patient's progress and needs." "SW will maintain at least monthly contact with parents/guardian regarding Patient's progress and needs." "SW will contact appropriate mental health and educational resources prior to discharge and assist in scheduling aftercare appointments."

d. Even though this patient participated in groups/activities, these modalities were not clearly identified and correlated to the stated goals in [his/her] treatment plan. Instead, Youth counselor (social work paraprofessional) interventions were listed as "Staff will offer pt.

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(patient) the chance for 1 :1 and group therapy to talk about situations [s/he] had used (sic) unhealthy coping skills." "Patient will be offered the opportunity for 1 :1 therapy to discuss coping skills identified."

4. Patient E10

For the problem "Paranoia" Patient E10, MTP there was no listed interventions for physicians or nursing. 5. Patient F1

a. For problem identified as "Recent increase in motor activity: hitting doors, windows and walls, jumping on furniture and throwing chairs," there were no physician or nursing interventions.

b. All interventions for this problem were assigned to a counselor (social work paraprofessional), including the safety interventions.

c. Even though Patient F1 presently very unorganized, irritable behavior -running around day room and jumping on furniture--during observations on 2/29/16 at 4:00 p.m. and on 3/1/16 at 9:15 a.m., there were counselor interventions listed that were inappropriate for the patient at this time. There were "Treatment materials on A. Coping Skills, B. Anxiety and C. Anger Management" and "Offer unit programming groups and activities as indicated on unit schedule."

6. Patient F5

a. For problem identified as "medication management: Pt (Patient) is off [his/her] prescribed medications and is very irritable,"

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{X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER:

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SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY



Youth counselor (social work paraprofessional) generic interventions were listed as "Maintain current level offunctioning." "Encourage patient to get involved in activities."

b. Even though this patient was receiving ECT {Electric Convulsive Therapy), there were no physician and nursing interventions listed. In addition, there were no nursing interventions to address this patient's irritability in the clinical area.

7. Patient G2

For the problem "Patient has a need for positive coping skills, as evidence by recent attempts of suicide". Patient G2, MTP interventions stated: a. "Psychiatrist will prescribe Ability and monitor patient for treatment of patient's depression." Frequency and duration not included. b. "Nurse will administer medication and monitor for effectiveness and side effects." c. "Nurse will provide feedback re: patient's timeliness and compliance of taking prescribed medications." 8. Patient H3

a. For problem, "assaultive behavior and anger outbursts," there were no nursing interventions to guide staff in the care of this patient in the clinical area when patient was showing assaultive behavior.

b. For problem, "ADHD evidenced by patient's impulsive behavior," the only nursing interventions were generic. These were: "Nurse will provide education re: benefits, side effects and risks" and "Nurse will administer medication and monitor for effectiveness and side effects." "Nurse will provide pharmacy pamphlets and education on prescribed medication and

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B 122

PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE


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B 122 Continued From page 13 diagnosis."

The intervention, "Nurse will provide education re: benefits, side effects and risks" was listed for another goal for this same problem.

c. For problem, "self-harm behavior," there were no specific nursing interventions to guide staff in the care of this patient in the clinical area. The only nursing interventions identified were generic. These were: "Nurse will provide education re: benefits, side effects and risks" and "Nurse will administer medication and monitor for effectiveness and side effects." "Nurse will provide pharmacy pamphlets and education on prescribed medication and diagnosis."

The intervention, "Nurse will provide education re: benefits, side effects and risks" was listed for another goal for this same problem.

d. For problem, "discharge/aftercare plan," generic social work interventions were listed as "SW (Social Work) will keep informed of patient's treatment progress and needs by weekly attendance at treatment team meetings." "SW will meet with patient as needed to discuss patient's progress towards transfer or discharge." "SW will maintain contact with guardian(s) regarding patient's progress and needs." "SW will contact appropriate resources prior to discharge and assist in scheduling aftercare appointments or placement."

B. Interview:

1. During interview on 3/1/16 at 11 :00 a.m. and review of active Patient D5's treatment plan, RN5 acknowledged that the nursing interventions were not individualized and were repeated in the plan.

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2. In an interview on 3/1/16 at 1 :45 P.M. with the Nurse Supervisor one (1) for the Adolescent units and Nurse Supervisor two (2) for the Acute Admission Units, the generic nursing interventions that do not include frequency and duration and the lack of nursing intervention on some MTPs were discussed. They both agreed intervention listed on some of the MTPs were regular RN responsibilities. Nurse Supervisor 1 stated "I see what you are saying." They also agreed that some of the MTP did not have nursing interventions listed. 3. During interview with review of treatment plans on 3/2/16 at 11 :00 a.m., the Director of Clinical Services and the Director of Social Work acknowledged that the social work interventions were not individualized. The Director of Social Work stated, "The interventions should be selected by each profession."

B 123 482.61(c)(1)(iv)TREATMENTPLAN

The written plan must include the responsibilities of each member of the treatment team.

This Standard is not met as evidenced by: Based on medical record review and interview, the responsibility for the implementation and evaluation for the majority of treatment plan interventions were assigned to a Counselor (Social Service paraprofessional), rather than to a professional treatment team member. This deficiency resulted in an inappropriate delegation of responsibility for patient treatment to non-professional unlicensed team members and confusion in the responsibilities of the team.

Findings include:

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B 123 8123 The treatment plan format for all patient reatment plans will be revised to include a

signature line on the Master Treatment Plan (MTP) and an initial box with responsible discipline with each intervention. All patients will receive an Initial Treatment plan upon admission which includes a signature from the responsible professional discipline.

The policy "Treatment Plan" will be reviewed and revised to ensure the appropriate level of responsibility for the identified problems, goals and interventions was assigned to the appropriate professional staff member of the reatment team.

Education on treatment planning process, the policy change, and the roles of each treatment earn member will be provided to all staff.

(X5) COMPLETION

DATE




(X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER:

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A. Record Review:

A. Review of treatment plans for eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87 (2/4/2016); 810 (2/16/16); 05 (1/28/16); E10 (dated 12/24/15); F1 (2/29/16); F5 (2/10/16); G2 (dated 12129/16) and H3 (10/6/15 with unclear review date) revealed that the majority of interventions were assigned to a counselor (unlicensed social work paraprofessional); these interventions included both 1 :1 and group therapies. All interventions in the treatment plan for one (1) of eight (8) sample patients (F1), including nursing interventions for safety, were assigned to the counselor.

8. Interview

1. During interview with review of treatment plans on 3/1/16 at 12:15 p.m., Nurse Supervisor one (1) and Nurse Supervisor two (2) acknowledged that the majoring of nursing interventions were role functions, rather than individualized based on patient needs.

2. During a conference with facility staff on 3116 at 1 :30 p.m., the Director of Social Work acknowledged that most groups/activities are delegated to non-licensed social work paraprofessionals (counselors).

3. During interview with review of treatment plans on 3/2/16 at 11 :00 a.m., the Director of Clinical Services and the Director of Social Work acknowledged that some of the treatment interventions that should have been assigned to professional staff were assigned to the counselors (unlicensed paraprofessionals).

8 125 482.61(c)(2) TREATMENT PLAN

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8 123 8123 continued

8125

rrhe Nurse Managers (2) will review 10% of all patient treatment plans to ensure the responsibilities of each member of the treatment ~earn are evident and appropriate for the level of licensure. Nurse Managers will report the findings of these reviews to the Director of Nursing or designee weekly for review and corrective actions. The DON or designee will report the results of these findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

l\ddendum: The DON or designee will report the results of reatment team audits to the Quality Council

monthly. The expectation is 100% compliance with treatment team members have appropriate evels of responsibility with appropriate licensure. Upon six months of 100%, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

(XS)

COMPLETION DATE

4/22/16

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The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included.

This Standard is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons. Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services in a Non-Distinct Part (non-certified) unit to the Distinct Part (certified) Unit integrated them with the adolescent patients who receive services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the quality treatment of patients receiving psychiatric services. (Refer to 899)

In addition, the facility failed to:

I. Provide active individualized psychiatric treatment, including alternative treatment interventions for one (1) of eight (8) active sample patients (87), who was not motivated to attend groups listed on the unit schedule. This patient spent many hours without structured activities spending most of his/her time in his/her bedroom or sitting in the day room. Failure to provide active treatment can result in longer hospitalization and delayed recovery.

II. Ensure that patients in one (1) of eight (8) units (C2) were offered treatment modalities on a regularly scheduled basis. There were no

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B 125 8125 Adolescent patients receiving chemical dependency treatment will be transitioned from he certified unit to other community inpatient

settings or discharged with completion of reatment. New admissions to the chemical

dependency program were discontinued.

Each patient residing on the certified unit receiving chemical dependency treatment will be assessed by the treatment team. Referrals and discharge plans to the appropriate level of care will be made and carried out.

!The policy and procedure Patient Unit Relocation will be reviewed and revised. This policy will include a review by the Administrator, Medical Director, Directors of Operations, Clinical Services, and Nursing, prior to any unit pombinations to ensure proper licensure for patients served. All temporary unit closures or combinations will be reported to the Director of Health Information and Quality Management.

IThe Director of Health Information and Quality Management will review the Patient Unit Closure ~hecklist to ensure that patients who were housed and treated in designated units/beds for acute psychiatric care are receiving services for ~he diagnosis and treatment of mentally ill persons. The Director of Health Information and Quality Management will report the findings of ~hese reviews to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary. ~ddendum: rhe Director of Health Information and Quality Management will report to Quality Council Monthly, the results of the reviews of Patient Uni1 Closure Checklist. The expectation is 100% compliance with no combining of units with ~ifferent licensure. Upon 6 months of 100% compliance, the Quality Council may indicate standards are met and reporting is no longer need to be required.

(X5) COMPLETION

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structured groups/activities offered on a regular basis for patients housed on the adult wing of Unit C2, including active sample Patient F5. Failure to provide sufficient hours of active treatment prevents patients from achieving their optimal level of functioning, thereby potentially delaying a timely discharge.

111. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients.

Specific findings include:

I. Provide active individualized psychiatric treatment:

A. Record Review


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8 125 8125 (1.) Self-paced worksheets and workbooks with

"ndividual staff review with patient will be provided as alternative treatment options. All patient treatment plans will be reviewed and revised to include options for active treatment based on the patient's assessed strengths, needs, and interests as needed. The policy ''Treatment Plan" will be reviewed

and revised to provide for the provision of alternative treatment. Treatment plans of current patients will be reviewed by the unit Charge Nurses to ensure inclusion interventions for providing alternative forms of active treatment as needed.

Education on the options available for active reatment and the policy change will be provided o all staff. Treatment plans of current patients will be reviewed by the unit Charge Nurses to ensure inclusion interventions for providing alternative forms of active treatment as needed. A unit treatment log will be created to monitor reatment participation and the provision of alternative treatment options for patients who refuse groups or are unable to participate. The Program Directors (2) will review unit

activity logs weekly to ensure the provision of alternative treatment options to patients. The Program Directors will report the results of the reviews to the Director of Clinical Services for review and corrective action to ensure compliance. The Director of Clinical Services will report the findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary. Addendum: The Director of Clinical Services will report the 4/22/16 results of activity log audits to the Quality Council monthly. The expectation is 100% compliance. Upon six months of 100% compliance, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.





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structured groups/activities offered on a regular basis for patients housed on the adult wing of Unit C2, including active sample Patient F5. Failure to provide sufficient hours of active treatment prevents patients from achieving their optimal level offunctioning, thereby potentially delaying a timely discharge.

Ill. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) ofthree (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety {spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients.



A. Record Review

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8 125 8125 (II) A schedule for active treatment groups was

~reated and implemented on Cedar 2 on 14/13/16. Self-paced treatment options will also be implemented on Cedar 2 for patients that were unable or did not wish to participate in group activities.

A unit treatment log will be created and implemented on Cedar 2 to track patient ·nvolvement in group or individual treatment.

Staff education on activity schedule, activity log, and self-paced treatment work will be provided for all Cedar 2 staff.

Program Directors (2) will review unit activity log weekly to ensure the providing of active reatment. Findings of these reviews will be

provided to the Director of Clinical Services for eview and corrective action. The Director of

Jclinical Services will report the findings to the Quality Council until the Quality Council ·ndicates standards are met and reporting is no onger necessary.

~ddendum: [Director of Clinical Services will report unit iactivity log audit results to Quality Council monthly. Expectation is 100% compliance. Upon 6 months of 100% compliance, Quality Jcouncil may indicate standards are met and eporting to Quality Council is no longer

required.

(XS) COMPLETION

DATE

14122/16





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Ill. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X1. X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients.



A. Record Review

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8 125 8125 (Ill) The policies related to physical restraints will

be reviewed and revised to ensure patient privacy when physical restraints are used. The use of the safety frame (transport board) will be discontinued. The safety frame will be removed from policy. Safety hoods will be removed from oolicy and use will be discontinued. The presence of a staff member on the unit was equired at all times when Cedar 2 is occupied

effective 3/2/16. Policy will be revised to add the RN reviewing documentation, assessing patient 'or earliest release from restraint or seclusion and documenting assessment at least hourly in he medical record or more frequently depending on patient need/condition or physician order. The Physical Restraint/ Chemical Restraint/ Seclusion Monitoring Progress Note will be revised to include a nursing assessment of patient behavior at least hourly or more Frequently depending on patient need/condition or physician order.

Safety Chairs will be ordered to replace the Safety frames. All staff will be provided education on the use of the Safety Chair and policy change. Defensive protective equipment (face shields and bite protection sleeves) will be ordered. All staff will be provided education on ~he use of the protective equipment and policy change. All staff will be provided re-education on he requirement for earliest possible release

~rom restraint or seclusion by the Human Rights !Specialist.

The Human Rights Specialist and the Director of Health Information and Quality Management will review each episode of the use of restraint or \Seclusion to ensure compliance. Any concerns will be reported to the Medical Director and ~dministrator for corrective action. Daily staffing \Sheets for Cedar 2 will be reviewed weekly by ~he Nurse Managers (2) to ensure staff presence on the unit when occupied. Findings of these reviews will be report to the Director of Nursing or designee weekly for review and corrective action. Each of the responsible parties above will report findings to the Quality Council until the

(X5) COMPLETION

DATE

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Ill. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X 1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. These patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients.



A. Record Review


ID PREFIX

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(X5) COMPLETION

DATE

8 125 8125 (Ill) Continued Quality Council indicates standards are met and

reporting is no longer necessary.

Addendum: DON or Designee will report results of staffing audits to Quality Council monthly. Expectation is 100% compliance, with C2 staffed when patients are on the unit. Upon 6 months of 100% compliance, the Quality Council may indicate standards are met and reporting is no longer needed. Director of Health Information and Quality Management will report audits of Seclusion and Restraint Events to ensure release at earliest time. Expectation is 100% ~ompliance. Upon 6 months of 100% ~ompliance, Quality Council May indicate standards are met and reporting to Quality Council is no longer required. 4/22/16

Addendum:

The Director of Health Information and Quality Management will report audits of Seclusion and Restraint Events and DON or designee will report audits of staffing sheets to the Quality Council monthly.





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1. Active sample patient 87 was admitted on 2/4/16, Psychiatric Evaluation dated 2/5/16 documented a diagnosis of "unspecified mood disorder," "unspecified anxiety disorder," and "unspecified personality disorder." Patient 87 problem was defined as "voices told pt. [sic] to stay outside in the cold because the toilet was going to blow up" and "refusing to take medications."

2. Shift note dated 2/5/2016 at 10:03 p.m. and written by HS Counselor states, "Patient spend shift sitting in the day hall, nonverbal for the most part". The registered nurse note for the same date stated, "Patient refused all prescribed medications and treatments this pm shift".

3. Nursing staff note dated 2/6/2016 at 9:49 a.m. and written by a registered nurse stated, "Patient spent the AM shift in bed". The pm shift 5:00 p.m., RN note stated "Patient spent the PM shift in bed". "She/he has refused all medications today as well as food". "Patient continues to lay (sic) in bed and stare at the ceiling." There is no indication that alternative interventions/modalities were offered to the patient.

4. HS counselor note dated 2/7/2016 at 6:45 p.m., stated, "Pt spend (sic) the entire shift resting in bed". Nursing staff note written by RN at 2:59 p.m., stated, "Patient continues to refuse to leave her/his room". The pm shift written by a RN at 5:41 pm, stated, "Patient continues to stay in her room although she/he has been up to the desk and sitting up in the bed at times on the PM shift."

5. Clinical Nurse Practitioner (CNP) note dated 2/8/2016 at 3:30 PM stated, "Patient refused to

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come to rounds today". "According to staff, she/he had still been not getting out of bed".

6. Recreational Therapy note dated 02/12/2016, stated, "Patient refused all offered Recreation groups during period 2/8/2016

through 02/12/2016

7. HS counselor noted dated 12/12/2016 at 8:46 PM, stated, "Pt spent the majority of the shift in front of the television". "pt had minimal interaction with staff or peers." "Pt kept to her/himself".

8. Nursing staff note dated 2/23/2016 at 5.57 p.m. and written by a RN, stated, "The patient has been sitting in the day hall much of the day". "He/she continues to refuse all medication ordered".

9. Shift note dated 2/28/2016 at 2.11 p.m. and written by a RN, stated, "Patient has been in room in her/his bed all shift except for meals and snacks". "Has not had interaction with peers or staff'. "Refused to take all medications".

8. Observations

1. On 2/29/16 at 3:15 a.m. the surveyor observed that active sample patient 87 was lying in bed and not attending the scheduled leisure education group that was in session on unit. No alternative treatment was assigned and patient was allowed to remain in the bed.

2. During observation on 3/2/16 at 9:30 a.m. the surveyor again observed active sample patient 87 was lying in and not attending the scheduled reality orientation group on unit.

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C. Interview

1. On 2/29/2016 at 4.05 p.m. RN6, charge nurse on the unit was asked about active treatment for sample patient 87, she stated "[Name of the patient] refused to attend treatment meeting. Does not participate in groups and usually in her/his room most of the time." When asked about alternative treatment for sample 87 the nurse response was, "She/he is not allowed to watch television".

2. On 3/2/2016 at 9.30 a.m. sample patient 87 was interviewed by the surveyor, stated, "She/he have (sic) gone to a few activities but refused most, I can't get up physically, maybe too drugged to wake up, I feel stuck here". "I was given the ok to go on off unit activity on 3/1/2016". "I did not go today but maybe I will go tomorrow".

II. Ensure that patients were offered treatment modalities:

A. Observations of the adult wing of C2 unit on 2/29/16 at4:10 p.m. and on 3/1/16 at 10:00 a.m. revealed active sample Patient F5 in bed and the other 3 adult patients sitting in front of the television.

8. During a conference with facility staff on 3116 at 1 :30 p.m., the Director of Clinical Services verified that there are currently no structured on-going groups/activities for the patients on the adult wing of the C2 Unit.

Ill. Appropriate use and documentation of seclusion/restraint:

A. Seclusion of patients in unit areas:

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1. During observations made on 2/19/16 at 4:00 p.m. and on 3/1/16 at 9:15 a.m., Patient F1 was found by the surveyor alone on the adolescent wing of Unit C2. Even though this ward could be seen through the nursing station window, the door to the office was locked; thereby the patient was locked on the adolescent wing without a staff member present.

2. During observations and interview with Patient F1 at the above listed times, this patient presented high levels of anxiety with disorganized, erratic behaviors. While secluded on this ward on 2/19/16, Patient F1was running about the dayroom and jumping on and off a chair.

3. During interview on 3/1/16 at 10:20 a.m., Mental Health Technician 8 reported that when the patients {including active sample Patient F5) on the adult wing are "resting in their rooms, we {staff) go into the office {indicating the nursing office adjacent to the patient dayroom)." When asked if the door to the nursing station is locked, she replied, "Yes, but we do our 15-minute checks {patient monitoring)."

4. During interview on 3/1/16 at 10:30 a.m. regarding the above findings, Nurse Supervisor 2 acknowledged that these patients had been secluded since the office door was locked and staff member{s) were not with the patients in the ward area.

B. Ambulatory Restraints

1. Discharged Patient X 1

As documented in an RN note {9/22/16), Patient X1 was transported from the hospital to another

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SOUTH DAKOTA HUMAN SERVICES CENTER

SUMMARY STATEMENT OF DEFICIENCIES

3515 BROADWAY AVE POST OFFICE BOX 7600 YANKTON, SD 57078

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town in wrist to waist and ankle restraints on 9/22/15. The physician's order on 9/22/15 at 10:18 a.m. was written as "Transport Restraint placed for safety of staff + [and] pt [patient] for discharge." There was no documented physician's note to support the use of this restraint based on an immediate threat to self or others.

2. Discharged Patient X2

According to an RN note on 12/11 /15 at 10:55 a.m. Patient X2 was "escorted to hearing in transport restraints due to history of aggressive behaviors et (and} comments of not being able to commit to safety." A counselor note on 12/11/15 stated, "Patient was transported in ambulatory restraints due to ensure (sic} ensure safety of staff, peers, property and patient." The physician's order on 12/11/15 at 12:10 p.m. was written as "Place pt (patient} in transport restraints for off unit hearing." There was no documented physician's note to support the use of this restraint based on an immediate threat to self or others.

3. Discharged Patient X3

a. According to a physician's history and physical examination (7/3/15) and 15-minute monitoring sheets, Patient X3 was placed in ambulatory restraint (wrist to waist and ankle} restraints on 7 /3/15 at 2:40 p.m. for "pulling out IVs et (and} attempting to pull out G tube." An MD note (7 /3/15) stated that this patient was "placed on ambulatory restraint at 1440 (2:40 p.m.} to prevent immediate harm to self or others." According to physician's orders, progress notes and 15 minute monitoring sheets, this patient remained in ambulatory restraints until 5:00 p.m.

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on 7/9/15. At times the patient was released from ankle restraints, but remained in wrist to waist.

b. The first physician's order on 7/3/15 at 2:10 p.m. stated "Ambulatory Restraints wrist and ankle." This order failed to include justification for use of the restraints nor the time allowed in restraints.

c. This patient was taken out in the hallways and dayroom several times. During this time, his/her privacy was not maintained as other patients were in these Unit areas.

A counselor note on 7/5/15 stated, "Patient will crawl moving his bottom in day hall." Another counselor note on 7/5/15 at 9:54 p.m. stated "Patient spent the evening scooting around the day hall on his buttocks or lying on the floor in the day hall."

A counselor note on 7/6/15 at 3:12 p.m. documented, "While on the ground, the pt. (patient) would scoot on his butt through the hallways." Another counselor note on 7 /6/15 at 10:06 p.m. stated "Pt. (Patient) continues to lay (sic) on the floor of the day hall and slide around using his hands."

On 7 /8/15 at 4:04 p. m. an RN note stated "Pt. (Patient) has been sitting in the day hall chair this afternoon."

d. Some progress notes documented long periods where the patient was calm, but still not released from restraints:

1).An RN note on 7/6/15 at 4:56 a.m. stated "Pt. (patient) has rested on & (and) off 7 hours (sic). Pt has been lying (sic) on mat on floor in [his/her]

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room resting with eyes closed ... "

2).0n 7/8/15 at6:15 a.m. an RN note documented, "Patient rested for 7 hours with eyes closed ... Patient remains a (sic) 1: 1 while in ambulatories waist, wrist and ankle.

3).0n 7/9/15 at 6:00 a.m. an RN note documented "Pt (Patient) assessed for release and pt cont (patient continued) to be unable to commit to safety for self and others.

e. Review of the 15 minute monitoring sheets revealed long periods of time, even on the first day (7/3/15) that restraints were utilized, when there was no documented patient behavior that reflected immediate violence to self or others, yet during these time periods the patient was not released from the restraints.

C. Seclusion

1. Policy Review

a. Facility policy 5.2.3.3 titled "Seclusion Policy (Medical Staff)", Revised 10/2/15, states, "It shall be the policy of the SDHSC that the use of seclusion may only be used to ensure the immediate physical safety of a patient, a staff member, or others and must be discontinued at the earliest possible time".

b. Facility policy 5.2.3.3 titled "Seclusion Policy (Medical Staff}", Revised 10/2/15, Procedure E states, "Use of seclusion shall be ended at the earliest possible time. A patient shall be released form seclusion as soon as the patient is assessed to no longer be a danger to self or others".

2. Record review

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a. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2/18/16, sample patient 87 was placed in seclusion of2/1/16 at 1650 (4:50 p.m.) for "forced AOL's (Activity of daily living): combative & yelling". The patient continued on and off for the next fifty-five minutes the behavior of yelling/screaming/cursing and holding hands out in front of her/him until 5:45 p.m. At 5.45 p.m. to 6.45 p. m. the patient was described as sitting, holding hands out in front of her/him, awake, verbal communication to wall, standing, crying. At 6.45 p.m. to 8.30 p.m. patient was described sitting, verbal communication to wall, and standing. At 8.30 p.m. patient was released from seclusion.

b. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2/21/16, sample patient 87 was placed in seclusion of2/21/16 at 10.30 a.m. for the administration of forced medication of Ativan 1. mg for refusing medication p.o. (orally). The patient continued on and off for the next twenty minutes the behavior of yelling/screaming/cursing, refusing redirect, intrusive to peer until 11.00 a.m. At 11.00 a.m. the patient was described as sitting, awake, laughing/singing, crying and responding to unseen stimuli. At 12.30 p.m. patient was released from seclusion.

c. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2/17/16, sample patient 810 was placed in seclusion of2/17/16 at 10.25 a.m. after the administration of forced medication of Haldol 5mg and Ativan 2 mg IM (intermuscular). At 10.14 a.m. patient became agitated and states

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'Why did you use a dirty needle". "Pt. begins to clench his fists and begins crying". "Pt. entered recorders space with fists clenched in an aggressive manner''. "Seclusion initiated as pt. was a danger to others at 10.25 a.m.". The patient continued on and off for the next five minutes the behavior of pacing, crying, and threating. At 10.30 a.m. the patient was described as "eyes closed/respiration noted", "lying on floor/mat/bed sitting, until 12.15 p.m.at which time the patient was released from seclusion.

d. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2/19/16, sample patient 810 was placed in seclusion of2/19/16 at 1725 (5.25) p.m. after pt. approached and touch another peer." "pt. noted to get agitated et. Become verbally aggressive towards peer." Patient become resistive and combative towards staff during the administration of Haldol 5mg and Ativan 2mg IM at 1724 (5.24). At 1830 (6.30) p.m. the patient was described as "eyes closed/respiration noted", "lying on floor/mat/bed sitting, until 2125 (9.25) p.m.at which time the patient was released from seclusion.

e. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2/20/16, sample patient 810 was placed in seclusion of 2/20/16 at 0820 (8.22) a.m. after patient refused to take medication forced medication order was obtained for Zyprexa 10 mg IM and given. Patient struggled then became aggressive with staff during medication administration and was secluded at 8:22 a.m. The patient continued on and off for the next twenty-two the behavior of combative, standing,

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and sitting until 8:45 a.m. At 9:00 am the patient was described as "eyes closed/respiration noted and lying on floor/mat/bed until 10:31a.m. At 10:31 a.m. the patent was released from seclusion.

f. According to facility's "Physical restraint/chemical restraint/seclusion monitoring progress note" dated 2121/16, sample patient 810 was placed in seclusion of2/21/16 at 1108 (11 :08) a.m. Pt. has been hard to re-direct and very intrusive with boundaries of staff and peers. Pt. has increased self-talk, responding to unseen stimuli, and cannot remain on topic. Pt. offered oral PRN medications, and he/she refused them, shoving the pills in the sock he/she was holding. Physical hold was initiated and IM medication was administered. P. was asked to stay in his/her room to calm self, but became combative and attempting to assault staff. Seclusion was initiated at 11.1 O a.m. Starting at 11.15 staff observation documented patient to be awake, and lying on floor/mat/bed and other times sitting until 1500 (3:00). At 1502 (3:02) patient was released from seclusion.

3. Interview

On 3/2/2016 at 12:00 noon, the facility's Physical restraint/chemical restraint/seclusion monitoring progress note for sample patient 87 and B 10 was reviewed with Nurse Supervisors 1 and 2. Both Nurse Supervisor agreed with the finding that the patients were kept in seclusion longer than necessary. Nurse supervisor 1 stated "I see what you are saying". Nurse supervisor 2 stated "yes", they were no longer a danger to self and should have been released earlier

D. Safety Hoods (spitting hoods)

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Safety/Protective Hoods, rather than defensive gear used by staff, were unnecessarily used on patients who demonstrated a propensity for spitting on or biting staff. These restraints were used based on a treatment plan entry and without a physician's order for each occurrence.

1. Patient Review

a. Sample Patient H3

1 ). Review of active sample Patient H3's medical record revealed an RN note (2/27/16 at 10:49 a.m.) stating that a "safety hood (spitting hood) was applied" after the patient continued to struggle with staff. There was no documentation that this patient has been spitting or biting, nor was there a physician's order for the use of this restraint. An intervention assigned to a counselor (SW paraprofessional) was added to Patient H3's treatment plan on 2/8/16. This intervention stated "Staff will apply protective hood when patient is demonstrating imminent danger to self and others."

Based on the patient's behavior as documented in the medical record, it is not clear why this hood was used on Patient H3 since there was failure to document that s/he was spitting or biting.

b. Discharged PatientX1

As documented in an RN note on 9/22/15, "At 9:06 a.m. protective hood (spitting hood) was placed per treatment plan as patient was trying to spit and bite staff."

2. Policy Review

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Hospital policy, "5.2.3.11 Protective Hood," states "It shall be the policy of the SDHSC that a protective hood may be used on a patient that presents a demonstrated propensity to spit or bit during restraint application or physical holds. The protective hood shall be incorporated into the patient's treatment plan prior to use if the treatment team believes the demonstrated behavior may occur in future restraint application/physicals holds. Demonstrated behavior during past hospitalizations or in other treatment centers may be considered by the treatment team."

Even though the protective hood is a restraint, this policy failed to ensure that a physician's order was required.

E. Transport Boards (safety frame), rather than beds, were used to restrain patients. Use of the transport board for continued restraint may result in physical complications for the patient.

1. Review of active sample Patient H3's medical record revealed an RN note (2/27/16 at 10:49 a.m.) stating "Safety frame applied at 1323 (1 :23 p.m.)" after throwing a chair, screaming and hitting a staff member. Patient was released from "safety frame" at 2: 10 p.m. The physician's order stated, "Safety frame until no longer danger to self/others, not to exceed 2 hours." Review of the monitoring sheet revealed that the only behavior reflecting that the patient was upset while on the transport board from 1 :21 until 2:10 p.m. was "crying, yelling/screaming cursing" at 1 :30 p.m.

2. Observation of the transport board used by this facility on the morning of 3/2/16 revealed a transport board made by the Humane Restraint Company called a "transboard." It was a narrow,

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flat board made of hard material. This board was meant for brief use, rather than longer periods of time.

3. During interview on the morning of 312/16, the Director of Clinical Services reported that the hospital has been using the board for restraint as the hospital does not have restraint beds.

B 136 482.62 SPECIAL STAFF REOS FOR PSYCH HOSPITALS

The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

This Condition is not met as evidenced by: Based on observation, interview and document review, the facility failed to provide adequate numbers of registered nurses (RNs) on the night shift for six (6) of eight (8) patient care units (A 1, 81, 82, C1, 01 and 02). There was One (1) RN (Registered nurse) covering two (2) locked units, leaving one of the unit without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for a period of approximately four (4) hours. Based on "Patient Need Assessment" completed by the unit's Nurse manager indicated a high acuity level on each unit for two (2) MHT to closely monitor the patients and do all required paperwork for the unit in the absence of the RN. This pattern of staffing creates a potential safety risk for all the patients on all six (6) locked units. (Refer to 8150)

In addition, there was failure to provide adequate


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B 136 8136 Each licensed unit will be staffed with at least 1 RN per unit on each shift to ensure adequate RN $tatting.

~tatting patterns for RN staff will be reviewed and revised by the Director of Nursing to ensure RN coverage on each licensed unit. The staffing suide for the hospital will be revised to reflect adequate staffing provided for each unit.

rrhe daily staffing sheets will be reviewed weekly by the Nurse Managers (2) to ensure adequate $tatting levels. The results of these reviews will be reported to the Director of Nursing or k:lesignee weekly to address any problems noted. irhe DON or designee will report findings of the eviews to the Quality Council until the Quality

K;ouncil indicates standards are met and reporting is no longer necessary.

~ddendum: iThe DON or designee will report staffing audits to Quality Council monthly. The expectation is 100% compliance. Upon 6 months of 100% compliance Quality Council may indicate standards are met and reporting to Quality 14/22/16 Council is no longer required.

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clinical leadership by medical and nursing leadership to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in 8144 and lack of supervision of active nursing care delivered as documented in 8148.

B 144 482.62(b)(2) MEDICAL STAFF

The director must monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff.

This Standard is not met as evidenced by: Based on observation, interview and document review, the Clinical Director failed to:

I. Provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (81, 87, 05, F1, F5 and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to 8116)

II. Provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for four (4) of eight (8) sample patients (87, 810, F1 and F5). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B 117)

Ill. Ensure that treatment plans were developed by professional team members, rather than Counselors (Social Service paraprofessionals). This inappropriate delegation of responsibility for

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8136 8144(1) ~ template for completion of psychiatric evaluations was created to include orientation, memory functioning and/or intellectual runctioning in measurable, behavioral terms.

ifhe policy "Psychiatric Evaluation" was reviewed o ensure inclusion of orientation, memory

~unctioning and/or intellectual functioning in measurable, behavioral terms.

B 144 Education will be provided to all Psychiatry staff pn the standards for psychiatric evaluation and he template for completion. Monthly meetings

between the Medical Director and Psychiatric $taff will be scheduled.

Director of Health Information and Quality Management will review 10% of all psychiatric evaluations each month for inclusion of orientation, memory functioning and/or intellectual functioning in measurable, behavioral erms. The Director of HI/QM will report findings

weekly to the Medical Director. The Medical Director will meet monthly with Psychiatric Staff o review and continue to educate to ensure

pompliance. Psychiatric staff performance out of compliance will be referred to Medical Executive committee and President of Medical Staff for corrective actions. ~ddendum: iThe Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of Orientation, memory functioning and/or intellectual functioning in measurable terms to the Quality Council. The expectation is 100% ~ompliance. Upon 6 months of 100 % ~ompliance, the Quality Council may indicate $tandards are met and reporting to Quality Council is no longer required. ~ddendum: ifhe Director of HI/QM will report findings of raudits of Psychiatric Evaluations for inclusion of prientation, memory functioning and/or intellectual functioning in measurable, behavioral terms.to the Quality Council monthly.

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clinical leadership by medical and nursing leadership to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in 8144 and lack of supervision of active nursing care delivered as documented in 8148.




I. Provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (81, 87, 05, F1, FS and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to 8116)

II. Provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for four (4) of eight (8) sample patients (87, 810, F1 and FS). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B 117)

Ill. Ensure that treatment plans were developed by professional team members, rather than Counselors (Social Service paraprofessionals). This inappropriate delegation of responsibility for

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8136 8144(11) ~ template for completion of psychiatric ~valuations was created to include an assessment of patient assets in descriptive ~ashion.

:rhe policy "Psychiatric Evaluation" was reviewed lo ensure inclusion of an assessment of patient assets in descriptive fashion.

Education will be provided to all Psychiatry staff B 144 bn the standards for psychiatric evaluation and

he template for completion. Monthly meetings between the Medical Director and Psychiatric staff will be scheduled. Director of Health Information and Quality Management will review 10% of all psychiatric evaluations each month for inclusion of an assessment of patient assets in descriptive 'ashion. The Director of HI/QM will report Jindings weekly to the Medical Director. The Medical Director will meet monthly with Psychiatric Staff to review and continue to educate to ensure compliance. Psychiatric staff performance out of compliance will be referred to Medical Executive committee and President of Medical Staff for corrective actions.

Addendum: The Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of an assessment of patient assets in descriptive 'ashion to the Quality Council. The expectation is 100% compliance. Upon 6 months of 100 % compliance, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required. ~ddendum: [fhe Director of HI/QM will report findings of audits of Psychiatric Evaluations for inclusion of an assessment of patient assets in descriptive ~ashion to the Quality Council monthly.

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DEPARTMENT OF HEALTHAND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES



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clinical leadership by medical and nursing leadership to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in B 144 and lack of supervision of active nursing care delivered as documented in 8148.




I. Provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for six (6) of eight (8) sample patients (81, 87, 05, F1, F5 and H3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B 116)

II. Provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for four (4) of eight (8) sample patients (87, 810, F1 and F5). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B 117)

111. Ensure that treatment plans were developed by professional team members, rather than Counselors (Social Service paraprofessionals). This inappropriate delegation of responsibility for

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B 136 8144 (Ill) rThe treatment plan format will be revised to reflect the creation of the treatment plan by icensed members of the treatment team.

rThe policy "Treatment Plan" will be reviewed and revised to define the treatment team members responsible for the creation of the treatment plan ias licensed staff in the disciplines of Psychiatry, Nursing, Social Work, Occupational Therapy, Physical Therapy, Dietetics, and Speech

B 144 rTherapy. The Class Specification for the position Human Services Counselor will be reviewed and evised. The development of patient treatment

will be removed from the job function.

Education on the new treatment plan format and policy revision will be provided to all staff.

The Nurse Managers (2) will review 10% of all patient treatment plans to ensure the treatment plans were created and developed by licensed members of the treatment team. Nurse Managers will report the findings of these reviews to the Director of Nursing or designee weekly for review and corrective actions. The DON or designee will report the results of these "indings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: The DON or designee will report the results of reatment plan audits to the Quality Council

monthly. The expectation is 100% compliance with treatment plans created and developed by professional members. Upon six months of 100%, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

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patient treatment planning to non-professional unlicensed team members resulted in treatment plans that were not individualized based on individual patient needs. (Refer to 8118)

IV. Develop treatment plans that clearly delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87, 810, D5, E10, F1, F5, G2 and H3. Instead most of the interventions for these professionals were routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to 8122)

V. Ensure that responsibility for the implementation and evaluation for the majority of treatment plan interventions were assigned to a Counselor (Social Service paraprofessional), rather than to a professional treatment team member. This deficiency resulted in an inappropriate delegation of responsibility for patient treatment to non-professional unlicensed team members and confusion in the responsibilities of the team. (Refer to 8123)

VI. Ensure that patients who were housed and treated in designated units/beds for acute psychiatric care were receiving services for the diagnosis and treatment of mentally ill persons. Due to low patient census the facility moved the adolescent patients receiving chemical dependency rehabilitation services to the unit providing services for the diagnosis and treatment of mental illness. This practice results in improper use of areas/services certified for the delivery of acute psychiatric care and impacts the

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8 144 IB144(1V) rT"he treatment plan format for all patient lreatment plans will be changed to clearly indicate the involvement of professional staff. rT"he new format allows for individualization specific to patient's assessed strengths, needs, and interests.

Education will provided to all staff on treatment planning, the individualization of treatment plans, and the roles of professional staff in the reatment planning process.

The Nurse Managers (2) will review 10% of all patient treatment plans to ensure proper delineation of interventions for professional staff. Nurse Managers will report the findings of these eviews to the Director of Nursing or designee

weekly for review and corrective actions. The DON or designee will report the results of these findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: The DON or designee will report the results of reatment plan audits to the Quality Council

monthly. The expectation is 100% compliance with treatment plans defined proper delineation of interventions for professional staff. Upon six months of 100%, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

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IV. Develop treatment plans that clearly delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87, 810, 05, E10, F1, F5, G2 and H3. Instead most of the interventions for these professionals were routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to 8122)



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8 144 8144 (V) The treatment plan format for all patient

lreatment plans will be revised to include a ~ignature line on the Master Treatment Plan (MTP) and an initial box with responsible ctiscipline with each intervention. All patients will eceive an Initial Treatment plan upon admission

which includes a signature from the responsible professional discipline.

The policy "Treatment Plan" will be reviewed and revised to ensure the appropriate level of esponsibility for the identified problems, goals

and interventions was assigned to the appropriate professional staff member of the treatment team.

Education on treatment planning process, the policy change, and the roles of each treatment earn member will be provided to all staff. The Nurse Managers (2) will review 10% of all patient treatment plans to ensure the responsibilities of each member of the treatment earn are evident and appropriate for the level of licensure.

Nurse Managers will report the findings of hese reviews to the Director of Nursing or

designee weekly for review and corrective actions. The DON or designee will report the esults of these findings to the Quality Council

until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: The DON or designee will report the results reatment team audits to the Quality Council

monthly. The expectation is 100% compliance with treatment team members have appropriate levels of responsibility with appropriate licensure. Upon six months of 100%, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

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IV. Develop treatment plans that clearly delineated physician, nursing and social work interventions to address the specific treatment needs of eight (8) of eight (8) active sample patients (dates of plans in parentheses): 87, 810, D5, E10, F1, F5, G2 and H3. Instead most of the interventions for these professionals were routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to 8122)



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8 144 8144 (VI) Adolescent patients receiving chemical

dependency treatment will be transitioned from he certified unit to other community inpatient

settings or discharged with completion of reatment. Each patient residing on the certified unit who

are receiving chemical dependency treatment will be assessed by the treatment team. Referrals and discharge plans to the appropriate level of care will be made and carried out. The policy and procedure Patient Unit Relocation will be reviewed and revised. This policy will include a review by the Administrator, Medical Director, Directors of Operations, Clinical Services, and Nursing, prior to any unit combinations to ensure proper licensure for patients served. All temporary unit closures or ~mbinations will be reported to the Director of K:}uality Management.

The Director of Health Information and Quality Management will review the Patient Unit Closure Checklist to ensure that patients who were housed and treated in designated units/beds for '3cute psychiatric care are receiving services for ~he diagnosis and treatment of mentally ill persons. The Director of HI/QM will report the ~ndings of these reviews to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

~ddendum: rrhe Director of Health Information and Quality Management will report to Quality Council Monthly, the results of the reviews of Patient Uni1 Closure Checklist. The expectation is 100% tompliance with no combining of units with ~ifferent licensure. Upon 6 months of 100% pompliance, the Quality Council may indicate $tandards are met and reporting is no longer need to be required.

(XS)

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quality treatment of patients receiving psychiatric services. (Refer to 899)

VII. Provide active individualized psychiatric treatment, including alternative treatment interventions for one (1) of eight (8) active sample patients (87), who was not motivated to attend groups listed on the unit schedule. This patient spent many hours without structured activities spending most of his/her time in his/her bedroom or sitting in the day room. Failure to provide active treatment can result in longer hospitalization and delayed recovery. (Refer to 81251)

VIII. Ensure that patients in one (1) of eight (8) units (C2) were offered treatment modalities on a regularly scheduled basis. There were no structured groups/activities offered on a regular basis for patients housed on the adult wing of Unit C2. Failure to provide sufficient hours of active treatment prevents patients from achieving their optimal level of functioning, thereby potentially delaying a timely discharge. (Refer to 812511)

IX. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X 1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. Patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients

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CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY}

8 144 8144 (VII) Self-paced worksheets and workbooks with

individual staff review with patient will be provided as alternative treatment options. All patient treatment plans will be reviewed and revised to include options for active treatment based on the patient's assessed strengths, needs, and interests as needed. The policy "Treatment Plan" will be reviewed

and revised to provide for the provision of alternative treatment. Treatment plans of current patients will be reviewed by the unit Charge Nurses to ensure inclusion interventions for providing alternative forms of active treatment as needed.

Education on the options available for active ~reatment and the policy change will be provided ~o all staff. Treatment plans of current patients Will be reviewed by the unit Charge Nurses to ensure inclusion interventions for providing alternative forms of active treatment as needed. ~ unit treatment log will be created to monitor ~reatment participation and the provision of alternative treatment options for patients who refuse groups or are unable to attend. Education on the options available for active ltreatment, the unit activity log, and the policy change will be provided to all staff.

The Program Directors (2) will review unit activity logs weekly to ensure the provision of alternative treatment options to patients. The Program Directors will report the results of the reviews to the Director of Clinical Services for review and corrective action to ensure compliance. The Director of Clinical Services will report the findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary. ~ddendum: h°he Director of Clinical Services will report results of active treatment audits to the Quality Council monthly. The expectation is 100% compliance. Upon 6 months of 100% compliance, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

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IX. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. Patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients

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8 144 8144 (VIII) A schedule for active treatment groups was

created and implemented on Cedar 2 on 14113/16.

Self-paced treatment options with individual review with staff will be implemented on Cedar 2 ~or patients that were unable or did not wish to participate in group activities. Self-paced reatment options will be implemented on Cedar 2 for patients that are unable or did not wish to participate in group activities. A unit treatment log will be created and implemented on Cedar 2 to track patient involvement in group or individual treatment. Program Director will review unit activity log

weekly to examine the provision of active reatment using an audit form. Findings of these

reviews will be provided to the Director of Clinical Services for review and corrective action. The Director of Clinical Services will report the findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: The Director of Clinical Services will report results of Cedar 2 active treatment audits to the Quality Council monthly. The expectation is 100% compliance. Upon 6 months of 100% ~mpliance, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

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IX. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. Patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients


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8 144 8144 (IX) The policies related to physical restraints will be

reviewed and revised to ensure patient privacy When physical restraints are used. The use of lhe safety frame (transport board) will be ~iscontinued. The safety frame will be removed from policy. Safety hoods will be removed from policy and use will be discontinued. The presence of a staff member on the unit was required at all times when Cedar 2 is occupied effective 3/2/16. Policy will be revised to add the RN reviewing documentation, assessing patient for earliest release from restraint or seclusion and documenting assessment at least hourly in he medical record or more frequently depending

on patient need/condition or physician order. The Physical Restraint/ Chemical Restraint/ Seclusion Monitoring Progress Note was revised to include a nursing assessment of patient behavior at least hourly or more frequently depending on patient need/condition or physician order.

Safety Chairs will be ordered to replace the Safety frames. All staff will be provided education on the use of the Safety Chair and policy change. Defensive protective equipment (face shields and bite protection sleeves)will be ordered. All staff will be provided education on he use of the protective equipment and policy

change. All staff will be provided re-education on he requirement for earliest possible release

rrom restraint or seclusion by the Human Rights Specialist.to Quality Council is no longer required. The Human Rights Specialist and the Director

of Health Information and Quality Management will review each episode of the use of restraint or seclusion to ensure compliance. Any concerns will be reported to the Medical Director and Administrator for corrective action. Daily staffing sheets for Cedar 2 will be reviewed weekly by he Nurse Managers (2) to ensure staff presence

on the unit when occupied. Findings of these reviews will be report to the Director of Nursing or designee weekly for review and corrective action. Each of the responsible parties above will


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VIII. Ensure that patients in one (1) of eight (8) units (C2) were offered treatment modalities on a regularly scheduled basis. There were no structured groups/activities offered on a regular basis for patients housed on the adult wing of Unit C2. Failure to provide sufficient hours of active treatment prevents patients from achieving their optimal level of functioning, thereby potentially delaying a timely discharge. (Refer to 8125 II)

IX. Appropriately use and document seclusion/restraint as external controls of violence toward self and others for four (4) of eight (8) active sample patients (87, 810, F1 and H3) and three (3) of three (3) discharged patients (X 1, X2 and X3) reviewed for the use of these procedures. In addition, the facility failed to ensure privacy for discharged Patient X3 who was taken out into the areas (hallways and dayroom) while s/he was in ambulatory restraints. Patients were secluded/restrained without documented justification based on changing behaviors and there was failure to use proper release criteria for seclusion. Patients


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(XS) COMPLETION

DATE

8 144 8144 (IX) continued

eport findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: DON or Designee will report results of staffing audits to Quality Council monthly. Expectation is 100% compliance, with C2 staffed when patients are on the unit. Upon 6 months of 100% compliance, the Quality Council may indicate standards are met and reporting is no longer needed. Director of Health Information and Quality Management will report audits of Seclusion and Restraint Events to ensure release at earliest time. Expectation is 100% ~ompliance. Upon 6 months of 100% ~mpliance, Quality Council May indicate standards are met and reporting to Quality Council is no longer required.

\Addendum [The Director of Health Information and Quality Management will report audits of Seclusion and Restraint Events and DON or designee will report audits of staffing sheets to the Quality Council monthly.

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were secluded alone and with others on wards. One (1) of three (3) discharged patients (X3) was in ambulatory restraints continuously for almost 6 days. Safety (spitting) hoods, rather than defensive gear for staff, were used on patients, sometimes without proper justification. Transport boards were used inappropriately as restraint beds. These deficiencies resulted in safety risks, violations of the patients' right to be free from undue restraint and failure to ensure privacy for patients. (Refer to B 125 Ill)

B 147 482.62(d)(1) NURSING SERVICES

The director of psychiatric nursing services must be a registered nurse who has a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill.

This Standard is not met as evidenced by: Based on interview and document review, the Director of Nursing (DON) failed to meet the educational, or ongoing consultation and or training requirements necessary for her administrative position as Executive Nurse within this facility. This hinders direction to the nursing department and the level of care provided by nursing personnel.

Findings include:

A. Review of the Nursing Director's (DON) resume revealed that the DON did not have a Master's Degree in Psychiatric/Mental Health Nursing nor was in consultation with a Master's Degree Psychiatric/Mental Health Nurse. Ongoing training was not reflective either.


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B 144 8147 The DON will be provided consultation with a Master's of Psychiatric Nursing prepared RN as needed. Content and goals of each consultation will be documented and submitted by the ~nsultant to the hospital administrator.

Areas of focus will include treatment plan kjocumentation and review, staffing plan adherence, adherence to programming plan, ~valuation of nursing care provided at HSC and pther issues as needed.

rThe DON will participate in Psychiatric Nursing B 147 rrraining annually.

Documentation of consultation with Master's of Psychiatric Nursing prepared RN and annual training will be reviewed by the Administrator and documented in the DON's personnel file.

~ddendum: rrhe DON will be provided bi-monthly consultation with a Master's of Psychiatric Nursing prepared RN in addition to as needed consultation. The DON will participate in at least 8 hours of Psychiatric Nursing Training annually.

(X5) COMPLETION

DATE

Administrator will report to Quality Council audit of DON consultation and annual education at next monthly Quality Council meeting and quarterly after that. Expectation is 100% compliance in consultation hours and 100% compliance for annual education. Administrator will continue to report to Quality Council quarterly of monthly consultation compliance. Upon two reports of 100% compliance, Quality 4/22/16 Council may indicate standards are met and eporting to Quality Council is no longer

required.





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B. Interview

In an interview on 2/1/16 at 2:15 P.M. with the Hospital Administrator, the credentials of the DON were discussed. The Administrator agreed that the DON did not have a Master's Degree in PsychiatridMental Health Nursing. The Administrator stated that the hospital has a contract with a group that includes a Nurse with a Master's Degree in Psychiatric Mental Health, but the relationship between this nurse and the DON does not reach the consultation level. In addition, he stated that he was not aware of any ongoing training currently pursued by the DON.


The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

This Standard is not met as evidenced by: Based on interview and document review, the Nursing Director failed to:

I. Ensure nursing interventions were included in the Master Treatment Plans (MTPs) based on the individual needs of eight (8) of eight (8) active sample patients (87, 810, D5, E10, F1, F5, G2 and H3). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery. (Refer to 8122)

II. Ensure patients in seclusion/restraint whose behavior no longer indicates they are a danger to

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B 147 8148 I. The treatment plan format for all patient treatment plans will be changed to clearly indicate the involvement of RN staff. The new format allows for individualization specific to patient needs and strengths.

Education will be provided to all RNs staff on treatment planning, the individualization of treatment plans, and the roles of professional $taff in the treatment planning process.

The Nurse Managers (2) will review 10% of all patient treatment plans to ensure proper delineation of interventions for RN staff. Nurse Managers will report the findings of these reviews to the Director of Nursing or designee weekly for review and corrective actions. The

8 148 DON or designee will report the results of these findings to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

The DON or designee will report the results of reatment plan audits to the Quality Council

monthly. The expectation is 100% compliance with treatment plans created and developed by professional members. Upon six months of 100%, the Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

(X5) COMPLETION

DATE





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B. Interview

In an interview on 2/1/16 at 2:15 P.M. with the Hospital Administrator, the credentials of the DON were discussed. The Administrator agreed that the DON did not have a Master's Degree in Psychiatric/Mental Health Nursing. The Administrator stated that the hospital has a contract with a group that includes a Nurse with a Master's Degree in Psychiatric Mental Health, but the relationship between this nurse and the DON does not reach the consultation level. In addition, he stated that he was not aware of any ongoing training currently pursued by the DON.


The director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

This Standard is not met as evidenced by: Based on interview and document review, the Nursing Director failed to:

I. Ensure nursing interventions were included in the Master Treatment Plans (MTPs) based on the individual needs of eight (8) of eight (8) active sample patients (87, 810, 05, E10, F1, F5, G2 and H3). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery. (Refer to 8122)

II. Ensure patients in seclusion/restraint whose behavior no longer indicates they are a danger to

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B 147 13148 (II.) The policies related to physical restraint will be revised to add the RN reviewing documentation, assessing patient for earliest release from restraint or seclusion and documenting assessment at least hourly in the medical record or more frequently depending on the patient need/condition or physician orders. The Physical Restraint/ Chemical Restraint/ Seclusion Monitoring Progress Note will be revised to include a nursing assessment of patient behavior at least hourly or more 'requently depending on the patient need/condition or physician orders.

Education will be provided to all staff regarding documentation and policies revisions.

8 148 The Nurse Managers will review Physical Restraint/Chemical Restraint/Seclusion Monitoring Progress Note following each restraint and seclusion event to ensure RN assessment is completed at least hourly. Any documentation out of compliance will be reported to CRN for corrective action with the RN failing to meet assessment standard. NM will report compliance to DON or designee who will report to Quality Council until QC no longer 'eels necessary to report.

Addendum: The DON or designee will report audit of Physical Restraint/Chemical Restraint/Seclusion Monitoring Progress Note to ensure appropriate and timely assessment by RN throughout seclusion and restraint event. Expectation is 100% compliance. Upon 6 months of 100% compliance, Quality Council may indicate standards are met and reporting to Quality Council is no longer required.

~ddendum: DON or designee will report findings of audits to ~he Quality Council Monthly.

(X5) COMPLETION

DATE





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self or others are release at the earliest possible time. (Refer to 8125)

Ill. Provide adequate numbers of registered nurses (RNs) on the night shift for six of eight patient care units (A1, 81, 82, C1, 01 and 02). There was 1 RN (Registered nurse) covering two locked units, leaving one of the unit without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for a period of approximately four hours. Based on "Patient Need Assessment" completed by the unit's Nurse manager indicated a high acuity level on each unit for two MHT to closely monitor the patients and do all required paper work for the unit in the absence of the RN. This pattern of staffing creates a potential safety risk for all the patients on all six locked units. (Refer to B 150)


There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.

This Standard is not met as evidenced by: Based on interview and document review, the Nursing Director failed to provide adequate numbers of registered nurses (RNs) on the night shift for six (6) of eight (8) patient care units (A 1, 81, 82, C1, 01 and 02). There was 1 RN (Registered nurse) covering two locked units, leaving one of the unit without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for a period of approximately four (4)


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B 148 8148 (Ill) Each licensed unit will be staffed with at least 1 RN per unit on each shift to ensure adequate RN staffing.

Staffing patterns for RN staff will be reviewed and revised by the Director of Nursing to ensure RN coverage on each licensed unit. The staffing guide for the hospital will be revised to reflect adequate staffing provided for each unit.

The daily staffing sheets will be reviewed weekly by the Nurse Managers (2) to ensure adequate staffing levels. The results of these reviews will be reported to the Director of Nursing or designee weekly to address any problems noted. The DON or designee will report findings of the reviews to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

Addendum: The DON or designee will report staffing audits

B 150 o Quality Council monthly. The expectation is 100% compliance with having each unit staffed With an RN for all shifts. Upon 6 months of 100% compliance, Quality Council may indicate ~tandards are met and reporting to Quality

(X5) COMPLETION

DATE

\Council is no longer required. 4/22/16





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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, Cl1Y, STATE, ZIP CODE


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self or others are release at the earliest possible time. (Refer to 8125)

Ill. Provide adequate numbers of registered nurses (RNs) on the night shift for six of eight patient care units (A1, 81, 82, C1, 01 and 02). There was 1 RN (Registered nurse) covering two locked units, leaving one of the unit without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for a period of approximately four hours. Based on "Patient Need Assessment" completed by the unit's Nurse manager indicated a high acuity level on each unit for two MHT to closely monitor the patients and do all required paper work for the unit in the absence of the RN. This pattern of staffing creates a potential safety risk for all the patients on all six locked units. (Refer to B 150)


There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.

This Standard is not met as evidenced by: Based on interview and document review, the Nursing Director failed to provide adequate numbers of registered nurses (RNs) on the night shift for six (6) of eight (8) patient care units (A 1, 81, 82, C1, 01 and 02). There was 1 RN (Registered nurse) covering two locked units, leaving one of the unit without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (Mental Health Technicians) for a period of approximately four (4)


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B 148

8150



Each licensed unit will be staffed with at least 1 RN per unit on each shift to ensure adequate RN ~taffing.

$taffing patterns for RN staff will be reviewed B 150 ~nd revised by the Director of Nursing to ensure

RN coverage on each licensed unit. The staffing guide for the hospital will be revised to reflect adequate staffing provided for each unit.

rrhe daily staffing sheets will be reviewed weekly by the Nurse Managers (2) to ensure adequate $taffing levels. The results of these reviews will be reported to the Director of Nursing or ~esignee weekly to address any problems noted. rrhe DON or designee will report findings of the reviews to the Quality Council until the Quality Council indicates standards are met and reporting is no longer necessary.

~ddendum: rrhe DON or designee will report staffing audits lo Quality Council monthly. The expectation is 100% compliance with having each unit staffed With an RN for all shifts. Upon 6 months of 100% compliance, Quality Council may indicate

(X5) COMPLETION

DATE

$tandards are met and reporting to Quality 14122/16 Council is no longer required.





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SOUTH DAKOTA HUMAN SERVICES CENTER

SUMMARY STATEMENT OF DEFICIENCIES

3515 BROADWAY AVE POST OFFICE BOX 7600 YANKTON, SD 57078

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hours. Based on "Patient Need Assessment" completed by the unit's Nurse manager indicated a high acuity level on each unit for two MHT to closely monitor the patients and do all required paper work for the unit in the absence of the RN. This pattern of staffing creates a potential safety risk for all the patients on all six (6) locked units.

Findings include:

A. Overview Information:

A review of the "Minimum Therapeutic Staffing and Emergency Staffing Guidelines" for the facility, which was provided by the Nurse manager, showed the "Acute Admission Program" (A1, A2, 81, C1 and C2) minimum number of RN staff for the night shift would be three (3) RNs with two units sharing one RN and two units have one RN on each unit. The Adolescent units (82, 01 and 02) required minimum RN staffing of .5 RN (1 RN supervising two (2) units).

B. Specific Findings:

1. Aspen1 (A 1) is a 15-bed acute admission unit for male and female adults

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) revealed that there was a census of 11 patients - 3 patients required diabetic checks, 1 IV's, 9 patients required skin care, and 1 Detox. Protocol, 1 patient was potentially assaultive, 2 patients were actively assaultive, 1 patient was a low risk for suicide, 3 patients were actively experiencing hallucinations/delusions, 1 patient took medications reluctantly, and 2 patients have

8150

()(5) COMPLETION

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medication problems (forced/non-voluntary).

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for 7 days including the first day of the survey (2/29/16), revealed that the night shift RN was assigned to supervise two units A 1 and 81 and had no replacement when she/he had to leave one unit to supervise the other unit.

On 2/27/16 there was only 1 RN assigned on the night shift to supervise A 1 and 81.

2. 8irch1 (81) is a 15-bed acute unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) reveled that there was a census of 11 patients - 1 patient required seizure precautions, 3 patients required skin care, 5 patients were potentially assaultive, 1 patient was actively assaultive, 4 patients were low risk for suicide precautions, 4 patients were actively experiencing hallucinations/delusions, 2 patients took medications reluctantly, and 1 patient have medication problems

On 2/23/16 there was only 1 RN assigned on the night shift to supervise 81 and C1.




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On 2/27/16 there was only 1 RN assigned on the night shift to supervise 81 and A 1.



3. 8irch2 (82) is a 15 bed acute adolescent acute unit for male and female

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) reveled that there was a census of 9 patients - 1 patient required dressing changes, 1 patient required skin care, and 2 patients were on intermediate risk suicide.

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for 7 days including the first day of the survey (2/29/16), revealed that the night shift RN was assigned to supervise two units 82 and C1 and had no replacement when she/he had to leave one unit to supervise the other unit.


4. Cedar1 (C1} is a 23-bed acute admission unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) revealed that there was a census of 12 patients - 2 patients required diabetic checks, 3 patients required seizure precautions, 4 patients required skin care, and 1

ID PREFIX

TAG

8150



(X5) COMPLETION

CATE





434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



(X4)1D PREFIX

TAG




required neurological checks, 4 patients were potentially assaultive, 1 patient was on intermediate risk suicide, 4 patients were low risk for suicide, 4 patients were actively experiencing hallucinations/delusions, 2 patients took medications reluctantly, and 4 patients have medication problems ( forced/non-voluntary).

b. The "Direct Nursing Staffing Form" completed by the Nurse manager for 7 days including the first day of the survey (2/29/16), revealed that the night shift RN was assigned to supervise two units C1 and 81 (Birch 1) and had no replacement when she/he had to leave one unit to supervise the other unit.

On 2/23/16 there was only 1 RN assigned on the night shift to supervise C1 and 81.







5. Oak 1 (01) is a 20-bed Adolescent Intermediate unit for male and female unit.

ID PREFIX

TAG

B 150



(XS) COMPLETION

DATE





434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



(X4)1D PREFIX

TAG




a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) reveled that there was a census of 15 patients - 1 patient required seizure precautions, 2 patients were potentially assaultive, and 1 patient took medications reluctantly.

On 2/26/16 there was only 1 RN assigned on the night shift to supervise 01 and 02.



6. Oak 2 (02) is a 16-bed acute unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by an RN on the first day of the survey (2/29/16) reveled that there was a census of 7 patients - 1 patient required diabetic check, 2 patients were potentially assaultive, 2 patients were low risk for suicide precautions, 2 patients were actively experiencing hallucinations/delusions, 1 patients took medications reluctantly.




C. Interview

ID PREFIX

TAG

B 150



(X5) COMPLETION

DATE





434003



B. WING _________ _


OMB NO 0938-0391


03/02/2016



(X4)1D PREFIX

TAG




1. In an interview on 2129/16 at 4:25 P.M., with the RN-6 charge nurse on the unit Aspen 2 unit (A2); overall RN staffing was discussed and she indicated "Nurses may share two units on the night shift and the night shift nurse do not have a lunch break."

2. In an interview on 3/1/16 at 1:45 P.M. with the Nurse Supervisor 1 for the Adolescents program and Nurse Supervisor 2 the for the Acute Admission Program unit, the staffing information from the direct nursing staffing form were discussed. They both agreed that one RN is schedule on the night shift to cover two units. When the RN is present on one unit, the other unit has no RN coverage. In addition, they agreed that only two MHT is left on the unit when the RN is on one of two of the units assigned. When asked if coverage was adequate for the unit when the RN is absent, they both stated "no."

ID PREFIX

TAG

B 150



(X5) COMPLETION

DATE


CMS HSC Inspection

Documents

Transcript of CMS HSC Inspection