agency - nicholas alahverdian · agency for health care administration form approved x3) date...

Agency for Health Care Administration FORM APPROVEDX2) MULTIPLE CONSTRUCTION X3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIERICLIA A, BUILDING COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER,; B. WING

R

NAME OF PROVIDER OR SUPPLIERHL1 10049

STREET ADDRESS, CITY, STATE, ZIP CODE

11/29/2012

p 5187 STREET WESTMANATEE PALMS YOUTH SERVICES BRADENTON, FL 34210

X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EAC4 ID PROVIDER'S PLAN OF CORRECTION (EACH X5)PREFIX DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY

H 000) INITIAL COMMENTS H 000) Preparation and submission of this Plan ofCorrection does not constitute an

HOSPITAL admission of or agreement by the hospitalwith the facts alleged and the conclusions

REVISIT FOR COMPLAINT INVESTIGATION # as set out in this Statement of Deficiencies.2012008406 This hospital provides this plan of

correction in accordance with the

November 28-29, 2012 regulations, and the plan of correctiondocuments actions taken by the hospital to

Manatee Palms Youth Services had deficiencies address the cited deficiencies.

at the time of the visit, one Uncorrected and 4new deficiencies.

H 005 5OA-3 FAC CHILD ABUSE AND NEGLECT H 005

3) Child abuse and Neglect Policy Reporting.Each hospital admitting or treating children shall

formulate a child abuse and neglect policy andshall submit a copy of this policy to the

HOSPITALDepartment of Children and Family Services,Office of Emergency Medical Services, 1317

H 005 REVISIT FOR COMPLAINT INVESTIGATIONVVinewood Boulevard, Tallahassee, Florida201200840E32301.

59A-3 FAC CHILD ABUSE AND NEGLECT

A. Plan for Specific Findings for H COS: 12128!12

This Statute or Rule is not met as evidenced by: 1. The Unit Nurse documented a late

Based on record review and Interview, the feclUty entry in Client #1's medical record

failed to comprehensively implement its policy o. indicating that the client made an

Alleged Patient Abuse, Neglect, Exploltatlon allegation against Staff A regarding

Reporting and Investigation for 2 (#1 and 43) of 3 an event that occurred 11/11/12,

sampled clients in regards to implementing a

2, The Unit Nurse, who examined Clientcomprehensive Investigation of an allegation of 12126112abuse and implementing protection measures fc- 1 at the time of the alleged event,

the alleged victims. Falling to implement a policy also made a late entry Into the

of Alleged Patient Abuse places clients at risk. medical record documenting her

findings from the assessment of

patient following the event.

Findings include:3. The Unit Nurse documented her

assessment of Client #1 at the time of 12/28l1Z

the event on the HPR/ Incident reportform-

AHCA Form 3020-0001

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTAT E'S IGNA1;JtE T TLE X8 DATE

STATE FORM nne4 ZM 12 It coral valten enee

12/17/2012 17;35 No,; R480 P.0021018

Agency for Health Care Administration FORM APPROVED3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIER/CLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A, BUILDING

B. WING RHL710049 11/2912012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE448051 IT STREET WEST

MANATEE PALMS YOUTH SERVICES BRAVENTON, FL 3dz10

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION X5)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

H 005 Continued From page 1 H 005 4. Staff A has received NAPPI refresher 12128/12

training by a Certified NAPPI trainer.A,) A review of the facility's Alleged Patient Documentation of training is presentAbuse, Neglect, Exploitation Reporting and in Staff A's Individual personnel file.

Investigations policy, policy#RRE 011, lastreview date of 12111, found in section 7,1: If the 5. The Director of Risk Management 12/14112

alleged incident falls within the facility risk has documented on the incident

management reporting guidelines, the incident is report that Staff A was cleared toto be immediately documented on an Incident work by Child Protective Services and

Report form. 7,2: If the allegation of patient law enforcement investigation,abuse, neglect, abandonment, or exploitation is

alleged to have been perpetrated upon the 6. The Nurse Supervisor, who was

patient by any individual In the employ of the present at the time of the event on 12/28112

facility)... the Registered Nurse, CEO or 11/25, documented a late entrydesignee shall notify the Human Resources regarding the allegation in theDirector (HDR), 7.2.1: The HDR will advise the medical record of Client 43.CEO or designee to suspend without pay saidindividual immediately and to require the 7. The Nurse Supervisor, who assessedindividual to complete and forward any required Client #3 following the event on 12/28/12documentation of the alleged incident to the HDR 11125, documented a late entry of herand licensed Risk Manager no later than 24 assessment of the client in thehours after the alleged incident. 7.3.1:.,, whether medical record.

founded or unfounded, the HDR will initiate the

Counseling Review Process as described in the S. Staff 8 has been re-trained on MPYSHuman Resources Policy and Procedure Manual, policies regarding incident reporting 12128112An internal investigation of an alleged incident and abuse reporting.may be initiated by the facility's Licensed Acknowledgement of understandingHealthcare Risk Manager. Such investigation has been signed and placed in theshall result in a written report, employee's personnel file.

B,) During an interview conducted on 11/18112 B. Plan of Correction: H 005

11:45 a.m. with the Risk Manager (RM) regarding 9, All nursing staff have been re-tralnedClient #1 it was confirmed that Staff member B to document any allegations of abuse 12128/12

completed a facility event report regarding an in the client's medical record andaltercation that Client #1 was involved in on complete an HPR/ Incident report11/11/12 at approximately 6:10 p.m. The RM form.confirmed that Client #1 alleged that Staffmember A had choked him during the event Mal: 10. The Director of Risk Management or

occurred on 1111102 at 6:10 p.m,; she also designee utilizes a Certified 12!14/12

confirmed that this information was not NAPPI trainer to review any video

documented, that she had become aware of it involving allegations againstduring an interview with Client #1, (Review of staff members related to restraint

technique and documents on theIncident Report Addendum,

11. All Direct Care Staff (Mental Health 12/28112

Techs and Nurses) have been

trained to remove themselves from

any situation in which a client has

specifically targeted them In an

aggressive manner,

AHCA Form 3020-0001STATE FORM 08051 ZM8012 If eenUnuatlon 9nsa 2 of I,

12/1712012 17;35 No,; 8480 P.003/018

Agency for Health Care Administration FORM APPROVED

X3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDERISUPPLIEP/CLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

8. WING RHL710049 11129/2012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODEWill 518T STREET WEST

MANATEE PALMS YOUTH SERVICES BRADENTON, FL 34210

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ' ID PROVIDER'S PLAN OF CORRECTION XslPREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FVLL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H 005 Continued From page 2 H 00512. The Director of Risk Management or 12/14112

Client #1's clinical chart, revealed no designee notifies the Director of

documentation of the allegation made by Client Human Resources and Supervisor of

1 that he had been choked by Staff member A).staff via e-mail of any client or staff

The statement that was submitted by Staff allegations of abuse against staff

member B was reviewed and it was noted thatmembers and documents on the

the employee B alleged that Staff member AIncident Report Addendum.

manhandled" Client #1 during the 11/11/1213. All nurses have been re-trained to 12/28/12event. It was also noted that Staff member B had

document assessment of any clientdocumented "red marks" on Client #1's neck-injuries in the medical record and onDuring an interview conducted on 11!18!12 etthe Incident Report form.11/45 a.m. with the RM, she stated that even

though Staff member S had documented inperson(s) Rosponsible:writing her allegation of the event, that StaffNursesmember B had manhandled Client #1, she statedNurse Supervisorthat staff member B makes some "interesting" Director of Risk Managementallegations. The Risk Manager confirmed that noCertified NAPPI Trainerdocumentation was available that would indicate

that Client 91 had been assessed by anyoneother than Staff member A. who allegedly choked

How Monitored:Client V.Documentation of all trainings above are 12128/12C.) During an interview conducted on 11128/12 atmaintained in the Human Resources office

approximately 2:30 p.m. with Client #3, shestated that Staff member A "slammed me into the

The Nursing Supervisor reviews the Incident 12128112floor and took his hand and pressed his handreport, reviews the progress note entry and

against my face onto the floor. During anensures documentation of notification toInterview conducted on 11/18/12 at approximatelyguardian Is documented in the medical record3:49 p.m. with the Risk Manager, she confirmedand on the HPR/Incident report form for anythat she became aware of an event that occurredsignificant behavior s involving injury to a

on 11125/12 involving Client #3 due to anotherclient. Evidence of this audit consists of Nurse

agency coming to the facility on Monday,Supervisor's initials on the HPR Addendum.11/26/12 to investigate an allegation that Staff

member A physically abused Client #3 andThe Director of Risk Management confirms 12/28/12slammed her face on the floor on 11125112.notification to guardian of any incidentA review was conducted of a video for the eventInvolving injury is documented an thein the gym on 11125112 at 17:36 p.m. The videoHPR/Incident report form or explanation of whyshowed that Client #3 approached Staff membernot Is documented prior to her signing the HPR

A, approximately 10 feet in distance, came atand Addendum

him. It was noted that Clients appeared to bethe aggressor, that Staff member A caught theclient with his arm around the client's neck and

AHCA Form 3020.0001STATE FORM Rape ZMSQ12 If wn6nuallon oh"e -1011̀1T

1211712012 17:35 No,: 8480 P.004/018

Agency for Health Care Administration FORM APPROVEDX3) DATE SURVEYSTATEMENT OF DEFICIENCIES Xi )PROVIDER/SUPPLIERICLIA X2) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDINGS. WING R

HL11 U049 1112912012NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

44130 5187 STREET WESTMANATEE PALMS YOUTH SERVICES BR.ADENTON, FL 34210

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION V-9)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H 005 Continued From page 3 H 005

went to the floor, during the tape, another staffmember stood between this and the camera no(

giving a clear view of the face of the client or thehands of the staff member.

A 2nd review of the video was conducted on

11/29/12 at 9;40 a.m. At this review, the Risk

manager and NAPPI Trainer (D) was present.During an interview conducted on 11/19/12 at

9:40 a.m,, the Risk Manager confirmed that no

NAPPI trainer (Restraint trainer) had reviewedthe video/event for the use of a correct restraint

process. After review of the video, the NAPPItrainer confirmed that the use of the arm by Starmember A around the neck of Client 93 duringthe restraint was not something that we train for.We would want him to step away," The Risk

Manager stated: "he needs to remove himself."

A record review of a Restraint form, dated

11125/12, documented: Client 9-3 complains ofdiscomfort to left side of forehead.

D.) During an interview conducted on 11/28/12at 1:25 p.m. with the Human Resource Director,she confirmed that she was unaware of anyallegation of abuse involving staff member A.She stated that she is supposed to receivenotice of an allegation of abuse so she can

process them appropriately. She confirmed thatas of this date, 11/28/12. that Staff member Ahad not been suspended at any point during11112, even though the facility had documented2 events that involved allegations of abuse to

clients by the staff member.

E.) It could be determined that Client 01 andStaff member B had alleged that abuse hadoccurred during the 11/11/12 event. It could bedetermined that there was lack of

documentation regarding Client 41's statement,lack of assessment for

AHCA Form 3020-0001

STATE FORM oaee ZWQ12 If cwoin-Oom sheel I or 1;

12/17/2012 17;35 No,; R480 P.005/018

A enc for Health Care Administration FORM APPROVED

STATEMENT OF DEFICIENCIESX3) DATE SURVEY

X1)PROVIDER/SUPPLIER.C̀LIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

B. WING RHL110049 11129/2012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE4480 51" STREET WEST

MANATEE PALMS YOUTH SERVICES BR'ADENTON, FL 34210



DEFICIENCY


injury for Client #1 by someone other than thestaff member alleged to have committed the

abuse, lack of communication of the event to theHuman Resource Director and lack of protectionmeasures implemented by the facility to remove

Staff member A from the proximity of the allegedvictim during the investigation.It could be determined that the facility was

aware that Client 93 had alleged abuse in

regards to having her face slammed into the

gym floor as of 11126112. No documentation as

present In the Client's clinical chart regardingthe allegation. A review of the video revealedthat potentially an inappropriate restraint hadtaken place during the event Involving Client #2and that the facility had not reviewed the video

in regards to use of appropriate restraint

techniques until 11/29112 during the survey. No

documentation was made available that would

indicate the facility had removed Staff memberA for the protection of Client #3. HumanResources was unaware of the allegation made

by Client 03 as of an interview with HR on

11128112 at 1,25 p.m.59A-3 FAC INTENSIVE RESIDENTIAL

H 2651 59A-3 FAC INTENSIVE RESIDENTIAL H 265TREATMENT PROGRAM

TREATMENT PROGRAMA. Plan for Specific Findings for H 265:

4) Patient Rights. Each hospital shall develop14. The Unit Nurse documented a late 12/28112

and adopt policies and procedures to ensure the.entry Into the medical record that

notification was made to thefollowing rights of the patient: guardian of Client #2 of the noted

a) The right to refuse treatment and life-behaviors documented In the medical

prolonging procedures as specified underrecord.

Section 765.308, F.S.; 15. The Unit Nurse documented a late 12/28/12

b) The right to formulate advance directivesentry in Client 02's medical record

and designate a surrogate to make health caredocumenting the event of 11!11/12,

decisions on behalf of the patient as specifiedunder Chapter 765, F.S. The policies shall not

S. Plan of Correction: H 265Condition treatment or admission upon whether

16, All nurses have been re-educated to 12/28112or

document notification to legalguardians of events resulting in any

injury to a client.

17. All nurses have been re-educated to 12/28/12

Include detailed, objective

AHCA Form 3020-0001

STATE FORM eoAa ZM8g12 N acnflnuauon nnank 5 r 17

1211712012 17;36 No.: 8480 P.006/018

A enc for Health Care Administration FORM APPROVEDX3) DATE SURVEY

STATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIER/CLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

B. WING RNL110049 11/291207Z

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE4480 51'T STREET WEST

MANATEE PALMS YOUTH SERVICES BRADENTON, FL 3421D

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PP,OVIDER'SPLAN OF CORRECTION X5)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FU LL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY

H 265) Continued From page 5 H 265 documentation of events in the

medical record,

not the individual has executed or waived an

advance directive. In the event of conflict between 18. All nurses have been re-educated to 12126112

the facility's policies and procedures and the document notification to guardian in

individual's advance directive, provision should be the medical record of significantmade in accordance with Section 765.308, F.S. events involving the client.

Policies shall include:19. All nurses have been re-educated to 12/28/12

1. Provide each adult individual, at the time of the document notification to guardian of

admission as an inpatient, with a copy of 'Health significant events on all event reportsCare Advance Directives - The Patient's Right to HPR/Incldent reports) of significantDecide," effective 1-11-93, which is hereby events, specifically incidents involving

incorporated by reference, or with a copy of some injury to client,

other substantially similar document which is a

written description of Chapter 765, F,S,, regardingadvance directives; Person(a) ResPonslble:

Nurses

2. Providing each adult individual, at the time of

admission as an inpatient, with written information

concerning the health care facility's policies How Monitored:

respecting advance directives; and The Nursing Supervisor reviews the Incident 12/ZB/12

report, reviews the progress note entry and

3. The requirement that documentation of the ensures documentation of notification to

existence of an advance directive be contained in guardian Is documented in the medical record

the medical records. A health care facility which i3 and on the HPR/Incident report form for any

provided with the individual's advance directive significant behavior s involving injury to a

shall make the advance directive or a copy thereof client. Evidence of this review is demonstrated

a part of the individual's medical record. by the Nursing Supervisor initialing the HPR

Addendum,

c) The right to information about patient rights as

set forth In Section 381.026, F.S., and proceduresfor initiating, reviewing and resolving patientcomplaints;

d) The right to participate in the consideration of

ethical issues that arise in the care of the patient:

e) The right to personal privacy and confidentialityof information including access to information

contained in the patient's medical records as

specified under Section 395.3025,

AHCA Form 3020.0001

STATE FORM eve 2M8Q12 if eorNnueftn ahncl 13 er 17

12/17/2012 17:36 No.: B480 P.0071018



X7)PROVIDER/SUPPLIER;CLIA X2) MULTIPLE CONSTRUCTION COMPLETEDETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

B. WING RHL110049 1112912012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE4480 61ST STREET WEST

MANATEE PALMS YOUTH SERVICES BRADENTON, FIL 34210

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION XS)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE T

DEFICIENCY)

H 265) Continued From page 6 H 265

F.$.;

f) The right of the patient's next of kin or

designated representative to exercise rights on

behalf of the patient;

g) The right to an itemized patient bill uponrequest as specified under Section 395.301, F.S.;

h) The right to be free of restraints consistent wi-lhthe rights of mentally persons or patients as

provided in Section 394.459, F.S.

This Statute or Rule Is net met as evidenced by:Based on record review and staff interview, the

facility failed to promote the right of the client'snext of kin or designated representative toexercise rights on behalf of the client in regards to

notification to the next of kin of significant events

for 1 (#2) of 3 clients reviewed.

Findings include:

During a review of Client #2's clinical records, they

following nurse progress notes documented

events:

11/01/12 at 10:35 a.m.' Client aggressive early on

as evidenced by (AES) bursting thru doors on

milieu and hitting peers.11/08/12 at 0900 a.m.: Client displayingaggressive AED hitting peer11/25/12 at 9:40 a.m.: Client ran to a peer in angerand began to hit peer...

Further review of the chart revealed no

documentation in regards to the facility staff

attempting to notify Client #2's next of kin or

AHCA Form 3020-0001STATE FORM anew ZMEQ12 Nwntinuelien %heel 7 of 17

1211712012 17;36 No,; R480 P.008/018

A enc for Health Care Administration FORM APPROVED

X3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIEFICLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

8. WING R

HL110049 1112912012

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

4480 at "T

STREET WESTMANATEE PALMS YOUTH SERVICES BRADENTON, FL 34210

xa) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION xa)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY

H 265) Continued From page 7 H 265

responsible party of the significant events stated

above.

During a review of a video tape for an 11/11/12event that occurred at approximately 6:00 p.m.,Client 02 was observed to be physically hit on theback area by another peer. No documentation was

present in Client #Z's clinical chart in regards to

documentation of this event: no documentation

was present in regards Client #2's next of kin or

responsible party being notified of the event.

During interviews that were conducted on

11/29/12 at approximately 3:30 p.m, with the Risl;

Manager and the Director of Nursing, theyconfirmed that no further documentation was

available in regards to the facility having evidence

that they had appropriately notified the next of kinor responsible party in regards to the latter events.

H 268 UNCORRECTED H 288 59A-3 FAC INTENSIVE RESIDENTIAL

TREATMENT PROGRAM53A-3 FAC INTENSIVE RESIDENTIAL

TREATMENT PROGRAM A. Plan for Specific. Findings for H 288:

20. The therapist revised Client #2's 12/28/12

b) Treatment Planning. An initial treatment plan treatment plan to accurately reflect

shall be formulated, written and interpreted to the the aggressive behaviors documentedstaff and patient within 72 hours of admission. The in the record, as noted in this report.comprehensive treatment plan shall be developedfor each child by a multidisciplinary staff, within 14

days of admission. This plan must be reviewed at B. Plan of Correction: H 288

least monthly, or more frequently if the objective of 21. All therapists have been re-educated

the program indicate. Review shall be noted in the that the treatment plan must 12/28/12

record, A psychiatrist as well as multidisciplinary accurately reflect aggressiveprofessional staff must participate in the behaviors that have occurred with the

preparation of the plan and any major revisions. client during the month.

22. Therapists reviews all progressnote entries for the seven days prior 12128112

to individual therapy sessions and

documents any significant behaviors

noted for inclusion into the treatment

plan.

Person(s) Responsible:TherapistsDirector of Clinical Services

AHCA Form 3020-0001

STATE FORM asap ZM8012 If aor~InuaGon ahaei a al 17

12117/2012 17;36 No.; 8480 P.009/018



X1)PROVIDER/SUPPLIER/CLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDINGB. WING R

NAME OF PROVIDER OR SUPPLIERHL1 10049

STREET ADDRESS, CITY, STATE, 71P CODE1112912012

4480 91"T STREET WESTMANATEE PALMS YOUTH SERVICES BRADENTON, FL 34210

X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION xs)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H Z88 Continued From page 8 H 288 How Monitored:The Director of Clinical Services reviews every 12/28/12

1. The treatment plan shall be based on the treatment plan prior to It being filed into theassessment and shall include clinical medical record and audits to ensure behaviorsconsideration of the physical, developmental, documented on progress notes are included Inpsychological, chronological age, family, treatment plan.education, social and recreational needs. Thereason for admission shall be specified as shall

specific treatment goals, stated in measurable

terms, including a projected time frame, treatmentmodalities to be sued, staff who are responsiblefor coordinating and carrying out the treatment,and expected length of stay and designation ofthe person or agency to whom the child will be

discharged.

2. The degree of the family's involvement (parentor parent surrogates) shall be defined in thetreatment planning program,

3_ Collaboration with resources and significantothers shall be Included in treatment planning,when the treatment team determines it will notinterfere with the child's treatment.

4. Procedures that place the patient at physicalrisk or pain shall require special justification. Therationale for their use shall be clearly set forth In

the treatment plan and shall reflect the priorinvolvement and specific review of the treatment

plan by a child psychiatrist- When potentiallyhazardous procedures or modalities are

contemplated for treatment, there shall be

additional program specific policles governingtheir use to protect the rights and safety of the

patient. The facility shall have specific written

policiesand procedures governing the use of

electroconvulsive therapy or other forms ofconvulsive therapy. If such procedures are to beused they shall be carried out in a setting with

emergency equipment available and shall be

AHCA Form 3020-0001

STATE FORM mono ZM8012 M continuation shoal 9 of 17

12/1712012 17;36 No.; 8480 P.0101018

A en for Health Care Administration FORM APPROVED


K1)PROVIDERISUPPLIERJCLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

S. WING RHL110049 11129/2012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE00 51ar STREET WEST


X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x5)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H 288 Continued From page 8H 288

administered only by medical personnel whohave been trained in the use of such equipment.Policies and procedures shall insure that:

a. Electroconvulsive therapy shall not beadministered to any patient unless, prior to theinitiation of treatment, two child psychiatrists with

training or experience in the treatment of

adolescents, who are not affiliated with the

treating facility, have examined the patient,consulted with the responsible child psychiatristand have written and signed reports which show

concurrence with the administration of such

treatment. Such reviews shall be carried out only

by American Board of Psychiatry certified or

American Board of Psychiatry eligible child

psychiatrists;

b. All signed consultation reports, either

recommending or opposing the administration o,f

such treatment, shall be made a part of the

patient's clinical records;

c, Written informed consent of member of the

family authorized to give consent, and where

appropriate the patient's consent shall be

obtained and made a part of the patient's clinical

records. The person who is giving such consent

may withdraw consent at any time;

d, Lobotomies or other surgical procedures for

intervention or alterations of a mental, emotionalor behavioral disorder shall not be performed or,

patients.

This Statute or Rule is not met as evidenced by:

AHCA Form 3020.0001

STATE FORM aloe 7M8012 I! eenunuatlan hoot to er 17

12117/2012 17;36 No,; R480 P.0111018


X3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIERiCLIA X2) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER. A, BUILDING

B. WING RH L110049 11 /291201 E

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE4400 51n STREET WEST


Xd) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x5)PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H 288 Continued From page 10

Based on record review and interview, the

facility failed to ensure that a monthly treatment

plan review accurately reflected progress on

goals for Anger Management for 1 (#2) of 3

sampled clients in regards to lack of

documentation of reference to aggressiveevents involving Client #2 during the month of

review, 1111 Z.

Findings include:

A Record review of Client #2's clinical chartrevealed the following entries:

11/01/12 at 10:35 a,m.: Client aggressive earlyon as evidenced by (AEB) bursting throughdoors on milieu and hitting peers11108112 at 9;00a,m,: Client displayingaggression AEB hitting peer11/10112 at 2 p.m.: Client runs after peer to hit.,,

11111/12at approximately 6:00 p.m., a review of

a video for this client revealed a peer coming up

and aggressively hitting Client 02 on the

shoulders, subsequently Client 02 made an

attempt to reach and fight with the peer that hit

him.

11125/12 at 9:40 p.m.: Client ran to a peer in

anger and began to hit peer, he was restrained

for 2 minutes.

During a review of Client #2's monthly treatment

plan and progress summary, dated 11120112,page 5 documented Problem #2: AngerManagement. The Progress on goals and

objectives for the problem of AngerManagement stated the following: Overall,Client #2 continues to show significant gains in

his ability to manage his anger. He is able to

state proudly, "I no longer jump Into fights."When his anger does escalate, he can calm

himself down by talking to staff and preventinghimself from physically acting out, There was an

incident where a peer threw a

AHCA Form 3020-0001

STATE FORM eeua ZM0012 If WM11 ueUnn 4n nt 11 or 17

12/17/2012 17:37 No.: 8460 P.012/018


X3) DATE SURVEYSTATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPUERiCUA XZ) MULTIPLE CONSTRUCTION COMPLETEDAND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

8, WING RHL110049 11!29!2012

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

480 51ST STREET WESTMANATEE PALMS YOUTH SERVICES BRADENTON, FL 34210



DEFICIENCY)

H 2aa Continued From page 11

drink at him which resulted in an argument, buthe did not attempt to assault the peer, He had

only one recorded Incident of fighting this review

period and that Is when he got hit by a ball,

Being physically hit remains his one big trigger.He had one incident of walking out of class,

It could be determined that Client #2's MonthlyTreatment Plan review did not accurately reflectthe aggressive behaviors that had occurred on

the milieu with Client 42 hitting peers, During an

interview conducted on 11/28!12 at

approximately 1:00 p.m. with Client 92's

Therapist, she confirmed that the monthlyreview had no documentation of the aggressiveacts exhibited during the month by Client #2.

H 403395.0197(1)(b), F.S. PROGRAM

H 403 395,0197(1)(b), F.S. PROGRAM REQUIREMENTSREQUIREMENTS

A. Plan for Specific Findings for H 403: 12128n2

The internal risk management program shall 23. The Unit Nurse documented a late

include: entry in Client 91's medical record

b) The development of appropriate measures to indicating that the client made an

minimize the risk of adverse incidents to allegation against staff member A

patients, regarding an event that occurred

11!11!12.

S. 395.0197(1)(b), F.S.24, This Unit Nurse, who examined Client lzrzal2

S, 395.0197(5), F.S. 1 at the time of the event, also made

a late entry into the medical record

documenting her findings from the

assessment of patient following the

This Statute or Rule is not met as evidenced by: event.

Based on record review and interview, the

facility failed to ensure a comprehensive 25. The Unit Nurse also documented her 1z!a6r12

implementation of a Risk Management Program assessment of Client #1 at the time of

for 3 (#1, #2 and #3) of 3 reviewed clients in the event on the HPR/ Incident report

regards to lack of documentation of the event, form.

lack of assessment of the client for injury, lack of

documented implementation of pro-active 26. The events identified In the findings in 12129112

measures to protect Client 42's medical record have been

reviewed with the nurse: 11/01,11!09111/11, 11/25 and clarification

was made as to whether these

incidents warranted incident reportcompletion. If determined to warrant

incident report. Incident report was

completed.

AHCA Form 3070-0001

STATE FORM UPI] ZMBQ 12 IF connnu9don sheel 12 of 17

12/17/2012 17;37 No,; B480 P.013/018


STATEMENT OF DEFICIENCIES XIIPROVIDER/SUPPLIERICLIA X2) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBEF A. BUILDINGB. WING R

HL110049 1112912012

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE4400 51" STREET WEST


X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x5)

PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE ACTION SHOULD BE COMPLETE


DEFICIENCY)

H 403 Continued From page 12 H 403 27. The Director of Risk Management 121zs/12

documented her interview with the

the clients involved in events. Failure of a Risk nurse supervisor who was present

Management Program process can place during the event of 11125 with Client

residents at risk for non-recelpt of services and 3 end Staff Member A on the HPR1

can potentiate a system failure in regards to incident report tool.

minimizing risk for clients.28. The Director of Risk Management 1212e112

Findings include: documented her review of video of

11125 of Staff Member A and Client

A.)A review of the facility's policy for "Incident 43 with a Certified NAPPI Trainer and

Reporting Incident reporting form #RM301, last his feedback as to correct restraint

revised 12111, documented that the company process on the HPRlincident report

policy requires reporting before the end of the form.

shift or work day, The purpose of the pollcy was

stated to be that the incident report is a risk 29. The Director of Risk Management 12128112

management tool that notifies the hospital notifies the Director of Human

administration of potential areas of loss. It Resources and the Supervisor via e-

enables the hospital to take corrective action, mail of any allegations of abuse

reducing losses and improving the quality of Involving staff members,

health care provided in the hospital. The

procedure further outlined in section 2.0: An B. Plan of Correction: H 403

Incident Report should be filed for any adverse 1. All nurses have been re-educated to 1 Zr28112

incident including, but not limited to- document an assessment of the

2.2: An undesirable event occurs which appearsclient following a significant event

inconsistent with normal patient care,and document in the progress note.

2.4: An unusual event which does or may result

in personal and/or bodlly Injury.2_ All nurses have been re-educated to 12128112

2.6: An incident involving hostile action by a complete an incident report for any

patient, visitor or family member. significant event as well as document

2.10: Observed or alleged physical abuse of a notification to guardian of any injuries

patient by any staff member, such as any willful involved on the Incident report tool,

or threatened act that results in any physical,mental or sexual injury 3. The Director of Risk Management or

12;28112

A review of section 3.0, Information to be designee will utilize a NAPPI

entered on the Incident Report includes: date Certified Trainer in video review

and time of the Incident: the incident location, of significant events wherein a

the type of person involved a brief restraint is involved to ensure

description of the Incidentfeedback is elicited and documented

A review of section 3,14: The reporting staff on the HPRlincident report form as

member will forward the incident report to the part of the investigative process,

Milieu Supervisor or Unit Nurse for further4. The Director of Risk Management or 12lRe/12

designee will notify the Director of

Human Resources and Supervisorimmediately via e-mail of any

allegations of abuse against a staff

member.

AHCA Form 3020-0001

STATE FORM Rape ZM8012 If =n1m.sUon ergo 13 of 17

12/17/2012 17:37 No.: 8480 P.014l018


STATEMENT OF DEFICIENCIES X1)PROVI1DER/SVPPLIER/CLIA X2) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDINGB. WING R

HL110049 11 /29!2012

NAME OF PROVIDER OR SUPPLIER

TBRADIENTON, REET ADDRESS, CITY, STATE, 21P CODEo 5187 STREET WEST

MANATEE PALMS YOUTH SERVICES FL 34210




DEFICIENCY)


5. The Supervisor of the staff member will

documentation. If the incident includes patient remove the staff from the area, If

Injury the person completing the report must applicable, and suspend the employee

take the patient to the attending nurse .,.3,15: immediately pending full Investigation

documentation of notification of the Nurse, the by the facility and clearance of Child

patient's physician, ...the patient's Protective Services. Nursing

parent/guardian and others as indicated ...4.0: Supervisors and Lead Techs have

all incidents involving patients should be been trained regarding this,

documented in the patient's medical record.6, The HR Director maintains a log of 12128/72

B.)During an interview conducted on 11128/12 any allegations of abuse against staff

11:45 a.m. with the Risk Manager (RM) and follow up with supervisor If

regarding Client #1 it was confirmed that Staff documentation of suspension and

member 5 completed a facility event report disciplinary action is not received

regarding an altercation that Client #1 was timely.involved in on 11/11/12 at approximately 6:10

p.m. The RM confirmed that Client #1 alleged 7, Findings from investigations of 12128112

that Staff member A had choked him during the allegations against staff are

event that occurred on 11/11 /12 at 6:10 p.m.; reported to the Director of Human

she also confirmed that this information was not Resources and the Supervisor by the

documented, that she had become aware of it Director of Risk Management with

during an Interview with Client 41. (Review of Recommendations. The Director of

Client #1's clinical chart, revealed noHuman Resources and the Supervisor

documentation of the allegation made by Client determine the course of disciplinary

1 that he had been choked by Staff member action, If any,

A). The statement that was submitted by Staff

member B was revlewed and it was noted that 8. The Director of Risk Management or 1 z1z8112

the employee B alleged that Staff member A designee documents clearly any

manhandled" Client #1 during the 11111112 Interviews conducted with patients or

event, It was also noted that Staff member B staff during an Investigation of an event

had documented "red marks" on Client #1's on the HPR/Incident Report tool.

neck. During an interview conducted on

11128112 at 11:45 a_m. with the RM, she stated 9. All nurses have been re-educated that 12/zewz

that even though Staff member B had all significant events will be

documented in writing her allegation of the documented in the medical record in a

event, that Staff member B had manhandled detailed, objective manner.

Client #1, she stated that staff member B makes

some interesting" allegations. The Risk

Manager confirmed that no documentation was Person(s) Responsible:

available that would indicate that Client #1 had Nurses

been assessed by anyone other than Staff Nursing Supervisors

member A, who allegedly choked Director of Risk ManagementDirector of Human Resources

Lead Mental Health Techs

How Monitored:The Nursing Supervisor reviews the Incident 12/ZW12

report, reviews the progress note entry and

ensures documentation of notification to

AHCA Form 3OZO.0001

STATE FORM asap ZM6Q12 If eentlnuatlon cheat 1d of 17

12117/2012 17;37 No,; R480 P.015/018


X3) DATE SURVEY

STATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIERiOLIA AZ) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDINGB. WING R

HL110049 11/29/201 Z

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

4400 5197 STREET WEST

MANATEE PALMS YOUTH SERVICES BRADENTON. FL 3&210



TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATEDATE

DEFICIENCY)

H 403 Continued From page 14 H 403guardian is documented in the medical record 12!2ena

Client 01,and on the HPR/Incident report form for any

C,) A Record review of Client #2's clinical chart significant behavior s involving injury to a client

revealed the following entries; and initials the HPR Addendum.

11/01112 Q 10:35 a.m.: Client aggressive earlyon as evidenced by (AEB) bursting throughdoors on milieu and hitting peers

11/08/12 @ 9:00 a.m., Client displayingaggression AEB hitting peer

11111112@ approximately 6:00 p.m.. a review of

a video for this client revealed a peer coming up

and aggressively hitting Client ##2 on the

shoulders,11/25112 @ 9:40 p.m.: Client ran to a peer in

anger and began to hit peer, he was restrained

for 2 minutes.

A record review of the facility Occurrence logrevealed no entry for the latter 4 events for

Client #2.

During an interview conducted on 11128/12 at

approximately 11:45 a.m. with the Risk

Manager, she stated that no event reports had

been competed for Client #2 during the month of

1112012.

No documentation was made available for

review in regards to any assessment beingperformed by nursing staff to review for injury for

Client 42 when he was hit by his peer on

11/11112.

D.)During an Interview conducted on 11128/12 at

approximately 2:30 p.m. with Client #/3, she

stated that Staff member A "slammed me into

the floor and took his hand and pressed his

hand against my face onto the floor". During an

interview conducted on 11128112 at

approximately 3:49 p.m. with the Risk Manager,she confirmed that she became aware of an

event that occurred on 11/25112 involving Client

03 due to another agency coming to the facilityon Monday, 11126/12

AHCA Form 3020-0001

STATE FORMmap ZM8Q12 If .onllruetlon ahoat 15 ar 17

1211712012 17;37 No,; WO P.016/018

Agency for Health Care AdministrationFORM APPROVED

X3) DATE SURVEY

STATEMENT OF DEFICIENCIES X1)PROVIDER/SUPPLIERiCLIA X2) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING

B. WING R

HL11 OD491112W012


4460 51sT STREET WEST


X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION W)COMPLETE

PREFIX EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX EACH CORRECTIVE AC71ON SHOULD BE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATEDATE

DEFICIENCY)


to investigate an allegation that Staff member A

physically abused Client #3 and slammed her

face on the floor on 11 /25112.

During a review of a video for the event in the

gym on 11125/12 at 17:35 p.m,; the video

showed an event in the facility gym with several

clients and staff members. The video showed

that Client #3 approached Staff member A,

approximately 10 feet in distance, came at him.

It was noted that Client A appeared to be the

aggressor, that the staff member Caught the

client with his arm around the client's neck and

went to the floor, during the tape, another staff

member stood between this and the camera not

giving a clear view of the face of the client or the

hands of the staff member.

A 2nd review of the video was conducted on

11 /29112 at 9:40 a.m. At this review, the Risk

manager and a Nappi Trainer (D) were present.

During an interview conducted on 11/29112 at

9:40 a.m., the Risk Manager confirmed that no

Nappi trainer (Restraint trainer) had reviewed

he event for the use of a correct restraint

process. After review of the video, the Nappitrainer confirmed that the use of the arm by Staff

member A around the neck of Client 03 duringthe restraint was not something that we train for,

We would want him to step away." The Risk

Manager stated; 'he needs to remove himself'.

Record review of a Restraint form, dated

11125/12, documented: Client #3 complains of

discomfort to left side of forehead.

E) During an interview conducted on 11128/12 at

1:25 p.m. with the Human Resource Director,

she confirmed that she was unaware of any

allegation of abuse involving staff member A_

She stated that she is supposed to receive

notice of an allegation of abuse so she can

process them appropriately.

AHCA FDm1 3020-0001gene

STATE FORMZM8012 IrconlhuaUen Shoal 16 01 t7

12117/2012 17:37 No.: R480 P.017/018


STATEMENT OF DEFICIENCIES X1)PROVIDERISVPPLIER, CLIA X2) MULTIPLE CONSTRUCTION COMPLETED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. BUILDINGB. WING R

HL11004911129!2012


4480 51 °T STREET WEST


PLAN OF CORRECTION XS)X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER S



DEFICIENCY)


F.)It could be determined that Client #1 and

Staff member B had alleged that abuse had

occurred during the 11/11/12 event. It could be

determined that there was lack of

documentation regarding Client #1's statement,

lack of assessment for injury for Client 91 bysomeone other than the staff member alleged to

have committed the abuse, lack of

communication of the event to the Human

Resource Director and lack of protectionmeasures implemented by the facility to remove

Staff member A from the proximity of the allegedvictim during the investigation.It could be determined that the facility did not

implement its policy for documenting qualifyingevents that Client #2 was involved in either

hitting a peer or being hit by a peer, that it did

not document assessment for injury for Client

42, notify the physician or responsible party as a

result of the occurrences.

It could be determined that the facility was

aware that Client #3 had alleged abuse in

regards to having her face slammed into the

gym floor as of 11126112. No documentation was

present in the Client's clinical chart regardingthe allegation. A review of the video revealed

that potentially an inappropriate restraint had

taken place during the event involving Client #3

and that the facility had not reviewed the video

in regards to use of appropriate restraint

techniques until 11129112 during the survey, It

could be determined that no documentation was

made available that would indicate the facilityhad removed Staff member A for the protectionof Client #3. It could be determined that Human

Resources was unaware of the allegation made

by Client 43 as of an interview with HR on

11/28112 at 125 p.m.

AHCA Farm 3020-0001.

STATE FORMW9 ZM8012 R rlrnrhvobn snaM 17 of t

1211712012 17;38 No,; R480 P.018/018

FLORIDA AGENCY FOR HEALTH CARE ADMiNKTRATION

RICK SCOTTBoner Health Care for all Floridians

ELIZABETH DUDEK

GOVERNOR SECRETARY

December 7, 2012

Administrator

Manatee Palms Youth Services

4480 51st Street West

Bradenton, FL 34210

Dear Administrator: CCR# 2012008406

This letter reports the findings of a state complaint survey revisit conducted on November 28-29, 2012 by

representative(s) of this office.

Enclosed is the provider copy of the Statement ofDeficiencies and Plan of Correction, State (3020) Form,

which reference the uncorrected deficiencies and new deficiencies identified during the revisit.

Please provide a plan ofcorrection to this Field Office, in accordance with enclosed instructions, for the

identified deficiencies within ten calendar days of receipt of this fazed report. You will not receive a

copy of this report in the mail, you will only receive this faxed report. All deficiencies shall be corrected no

later than December 28, 2012.

The Quality Assurance Questionnaire has long been employed to obtain your feedback following survey

activity. This form has been placed on the Agency's website at

http://ahca.myflorida.com/Publications/Forms.shtml as a first step in providing a web-based interactive

consumer satisfaction survey system. You may access the questionnaire through the link under Health

Facilities and Providers on this page. Your feedback is encouraged and valued, as our goal is to ensure the

professional and consistent application of the survey process.

Thank you for the assistance provided to the surveyor(s). Should you have any questions please call Patricia

Reid Caufman at (727) 552-2000.

Sincerely,

7Patricia Reid Cau

Field Office Manag

PRC/dw

Enclosures

Headquarters St. Petersburg Field Office2727 Mahan Drive 525 Mirror Lake Drive North, Suite 410 A

Tallahassee, FL 32308 St. Petersburg, FL 33701

http://ahca.myforida.com Phone (727) 552-2000; Fax (727) 552-1162

agency - nicholas alahverdian · agency for health care administration form approved x3) date...

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