Behavioral Health Policy Collaborative, LLC
4923 Waple Lane ♦ Alexandria, VA 22304 ♦ (703) 566-1177
Virginia Behavioral Health Training Partnership
TO: Jeffrey Aaron, Facility Director
Tammy Peacock, Ph.D., DBHDS Project Officer
FROM: Richard Fields, M.D., Director of Hospital Survey Readiness
Gail P. Hutchings, M.P.A., Project Director
RE: Commonwealth Center for Children and Adolescents (CCCA):
Final Site Visit Report with Synopsis of Recommendations from Site Visit on April 28-30, 2015
DATE: May 27, 2015
We thank you for the time and support that you and your staff provided to BHPC’s consulting team (Valerie Devereaux, DPN, RN-BC, Richard Fields, MD, and Joseph J. Gigliotti, MSW) during their site visit to your organization on April 28-30, 2015. This work was conducted under DBHDS Contract #720C-04412-15B.
This memorandum provides you with an Executive Summary with prioritized recommendations followed by a more detailed Matrix Report of Key Findings and Recommendations based on the recent site visit. Since the triennial TJC survey was expected shortly after our site visit, a special effort was made to identify and prioritize immediate/short–term opportunities for improving standards compliance and survey readiness. When it was learned that the survey would, in fact, occur the following week (and prior to this report), an interim Pre-Report communique was also provided. A draft version of this report was submitted earlier for your review and comment for factual errors or omissions.
This report is designed to augment the oral exit summation provided on-site by Dr. Fields and the consulting team. We hope it will augment the ongoing efforts of you and your staff to meet standards improve quality and safety.
Should you have any questions or if we can be of further assistance, please contact Dr. Fields at (770) 389-3800 or . Other members of the consultation team can also be available for further report clarification and/or ongoing support of recommendation implementation.
Thank you.
Behavioral Health Policy Collaborative, LLC
4923 Waple Lane ♦ Alexandria, VA 22304 ♦ (703) 566-1177
Virginia Behavioral Health Training Partnership
On-Site Consultation to Commonwealth Center for Children and Adolescents (CCCA):
April 28-30, 2015
EXECUTIVE SUMMARY
On April 28-30, 2015 Valerie Devereaux, DPN, RN-BC, Joseph J. Gigliotti, MSW and Richard Fields, MD (team leader) performed a three-day consultation for the Commonwealth Center for Children and Adolescents (CCCA). The purpose of the site visit was to identify opportunities to improve the quality of patient care, safety and readiness for triennial accreditation survey. Key Consultation Activities included:
o Life Safety Code Building Tour, EOC/EM documents and plan review
o Mock Patient Care Tracers
o Mock System Tracers (Data and Medication Management)
o Mock Session Interviews (Leadership, Medical Staff)
o Exit Conference with prioritization of strategy recommendations
The last Joint Commission survey of CCCA ended on May 4, 2012. The next survey was expected soon after the conclusion of the BHPC site visit and was ultimately announced for May 12-14, 2015. Facility preparation for the mock survey was well organized and progressing in an appropriate manner. With a slight increase in pace, intensity and properly focused priorities, CCCA was expected to be reasonably prepared in time for survey.
It should be noted that during this visit our team observed a number of strengths for this organization to include:
o Executive leadership that is committed to improving.
o Staff who are caring and open to improvement suggestions.
o Staff who demonstrated patient, positive interventions with very challenging youth.
o A beautiful campus and buildings that are generally well maintained.
o Well done patient safety plans.
Given the above context and the relatively brief interim expected until survey, the following priorities are recommended for optimizing standards compliance and survey readiness:
Key Improvement Opportunities (Immediate/30 days)
o Re: Clinical
▪ Restraints – presence and authentication of orders, chair approval
▪ Medication Management – Med rooms, narcotic control, glucometers
▪ Treatment Plans – Problem specificity, authentication
▪ Infection Control – Hand hygiene/Targeted Solutions Tool
o Re: Non-Clinical
▪ Leadership – Talking points, Culture of Safety Assessment, HRO
▪ Competence – Traveling nurse orientation, LIP privilege dates
o Re: Environment of Care
▪ Plans - Risk identification/reduction, annual evaluations
▪ Life Safety - Alarm automatic notification ‘pause button’
▪ Unit 2 - Cleanliness
o Re: Survey Management
▪ Review Survey Activity Guide
▪ Identify key interview participants/talking point
▪ Patient engagement
▪ Unit level use of data
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Behavioral Health Policy Collaborative, LLC
4923 Waple Lane ♦ Alexandria, VA 22304 ♦ (703) 566-1177
Virginia Behavioral Health Training Partnership
Commonwealth Center for Children and Adolescents (CCCA)
Site Visit Findings & Recommendations (April 28-30, 2015)
CTS 05.06.05 / Staff are trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely / Documentation of restraint and seclusion observation did not consistently include evidence that staff were checking vital signs, assessing for circulation of wrists and ankles and /or assessing for proper placement and position of restraints, nor assessment and management of hydration, nutrition and elimination needs.
CTS 05.06.05 / Staff are trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely. / Documentation did not consistently reflect use of behavioral criteria for discontinuation of restraints or seclusion nor how the staff helped the client in meeting the criteria for release.
CTS 05.06.19 / Written and verbal orders for use of restraints are time limited. / Orders for restraint or seclusion were not consistently present and when telephone orders were written they were not consistently signed and validated by the ordering practitioner, in accordance with the facility policy. The facility should develop an internal monitoring system to track orders and documentation.
CTS.03.01.01: EP 2 / During Pt tracer record review, a treatment plan was observed to have been signed by only 2 of 5 team members / Ensure that all team members participating in the treatment planning and review process authenticate their participation and agreement with the plan as scribed.
CTS.03.01.03: EP 3 / Treatment plan problems and goals were not consistently documented in a manner that was measurable. / Consider using the 'AEB' as evidenced by approach when documenting problems and ensure each goal/objective has a frequency and focus that is measurable.
CTS.05.06.31: EP 1 / During Pt tracer related to restraint, a staff member who participated in the restraint episode was available, but was not aware that he was expected to participate in the subsequent debriefing. / Ensure that staff training on restraint includes informing staff of the expectation that staff actually involved in a restraint episode should participate in the debriefing process when available.
EC 02,02,01 (E1), (E2) Managing hazardous materials in the environment / The written plan for managing hazardous materials does not include risk identification and risk reduction/minimization. Two (2) chemicals were found in the housekeeping closet that are fatal if swallowed and can cause irreversible eye damage. / Plans should be revised and chemicals that pose serious risk replaced with chemicals that pose less risk. This should be a measureable goal and
performance indicator for this plan.
EC 02,03,01 (E10) / The written Fire Response Plan does not address containment nor extinguishment. / Suggest using the term R,A,C,E which is what is taught to staff and contains the terms C and E.
EC 02.01.01 (E1, (E3)) Risks based approach to identifying and minimizing risks in the environment, / The written EOC management plans do not reflect risk identification and risk minimization. / Each of the EOC management plans should be revised to include the functions of risk identification, risk
reduction and minimization.
EC 02.03,01 (E9) Written Fire response plan / The written plan is not consistent with the plan posted on the units. / Ensure consistency with the written plan and what is taught to staff.
EC 02.06.01 (E4) Access to outdoor space. / The agency has courtyard space and most children can access the space, however all children are not monitored to ensure that they have access during their stay. / Create monitoring of the use of outdoor space to ensure that all children have access to outdoor space.
EC 04.01.01 (E15) Annual evaluation of the EOC plans / The EOC plans had not been evaluated at the time of survey. / Establish performance indicators that measure risk reduction in each of the plans and evaluate their performance.
EC.02.05.07 (E6) Testing automatic transfer switches monthly / The facility tests the generator monthly, but does not clearly document the testing of the transfer switch. / Revise the testing form to include the term transfer switch.
EC.02.06.01 (E20) The environment is clean and appropriate / Unit 2 was very dirty at the time of survey in all areas including the courtyard. / Monitor the units for cleanliness on a daily basis. Collect and aggregate data for review in the EOC meetings
regarding the cleanliness of all units and track the data for trends and patterns.
HRM 01.03.01 STD / The organization provides orientation to staff. / Traveling agency RN’s personnel files did not contain evidence of completed orientation.
HRM 01.06.01 STD / Staff are competent to perform their job responsibilities. / Traveling agency RN’s personnel files did not contain evidence of completed competency assessments.
HRM.01.02.01: EP 6 / Privilege approval letters only indicate the month in which privileges begin. / Update privilege letters to include a specific date for commencement of privileges.
IC 02.02.01 / The organization reduces the risk of infection associated with medical supplies and devices. / Staff were not able to perform disinfection of a restraint chair and had
no supplies accessible.
The facility needs an updated policy on cleaning and disinfecting re-useable
medical devices.
IC 02.03.01 / The organization works to prevent the spread of infectious disease among individuals and staff. / There was no evidence that staff attempt to have clients cover their feet with shoes or stockings. There is no evidence of policy for terminal cleaning of beds or room upon discharge. The facility contracts out housekeeping services and there is no evidence of reviewed and accepted housekeeping policies.
LD 03.01.01 (E1) Culture of safety / The Leadership had not yet evaluated the agency's culture of safety. / Create a measurement tool and evaluate the culture of safety.
LD 03.03.01 (E7) Evaluate effectiveness of planning / The leadership does not utilize a strategic plan yet and has not evaluated the effectiveness of planning. / Initiate strategic planning, include all departments, create measureable goals and annually evaluate the effectiveness of planning.
LD 04.01.07 (E1) Leaders review and revise policies and procedures. / The EOC Policies and Procedures and the shared services agreement with Western Hospital are outdated by several years. / Review and update all agency policies and procedures including the shared services agreements.
LD 04.04.01 (E1) Leaders set PI priorities / At the time of survey, the leadership had not identified the agency PI priorities. / Create a process for leadership to identify and prioritize the agency PI priorities.
LD.03.05.01: EP 1-7 / During the leadership interview, leaders were not sufficiently familiar with the topic of high reliability or recent literature relating to culture of safety, just culture and robust process improvement. / Leadership was provided references on site (and on the SPHCC website) relating to High Reliability and Culture of Safety.
LS 04.01.30 (E4) Audible alarm that notifies occupants without delay / The agency has placed a “pause button” to silence the audible fire alarm. / Confirm with TJC Engineering Department that this practice is consistent with all chapters of the NFPA Life Safety Code. If deemed consistent, conduct a risk assessment of how the use of this pause button could lead to an adverse event.
LS 04.02.20 Fire exit signs are illuminated / On Unit #3 the Exit sign was burned out. / Replace the exit sign.
LS 04.02.30 (E12) Penetrations / There was a penetration in the corridor wall above the exit door. / Seal the penetration with appropriate material. This wall was thought to be a fire wall per the diagram
MM 03.01.03 / The organization safely manages emergency medications and supplies. / The organization did not have available evidence that emergency medical
equipment is routinely checked to assure readiness, such as oxygen
and suction.
MM 05.01.07 STD / The organization safely prepares medication for administration. / The organization did not assure a safe system for storage and accountability of controlled substances.
MM 05.01.09 EP 7 / All individualized medications that are dispensed or administered to individuals are labeled with the individual’s name. / Ointments belonging to individual clients were not labeled with the individual’s name or directions for use.
NPSG 01.01.01 STD / Use at least two identifiers when providing care, treatment and services. / Not all nursing staff interviewed were able to name the facilities two identifiers.
Sentinel Event/RCA / The organization has not updated its definition of Sentinel event. Risk reduction actions are not always monitored/evaluated against predefined indicators of success. / Update Sentinel Event definition. Consider defining measurable indicators of risk reduction for root cause improvement actions.
WT 01.01.01 / Policies and procedures for waived tests are established, current, approved and readily available. / Procedure for waived testing was not current or readily available.
WT 04.01/01 / The organization performs quality control checks for waived testing on each procedure. / The glucometer reviewed did not have a document with evidence of quality control checks and, the glucometer device container nor cabinet where it is stored, had
evidence of appropriate control solutions.
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