0310512012 13:52 thing b~ D7bJOL L}~ a6` W tl~: STATEMENT OFOEPCIENCV AND PLAT. OF 00RR9trich i bLT Itl tr ` rr PRINTED: 020/2012 FORM APPROVED goIV for Wealth 5traticta QsrrAdmi? 5i; a P. 0021004 A' 9047243797 i) L~ 1T d bv. L' T c 7i': G:b~ Xi}f2l8E1PPL11wR1ri, PR~~ 1iJ~ l A 1 14ENTIFICATION NUMBER: JDAT! 41URV?Y X)MULTIPLE p~ C0N$ TRU0T~ COMPLETED h,6Klsi`e a. WtNG1l Fi~$ bdPl~$ 021141201NAM o ON PROM DER OR SUPPLfER SIRES T ADORE58, CITY, STATE, ZIP 00 6301 BEACH BLYD RIVER POINT REHA.ViQrRAL HEALTH x4)36 PREFIX 7A0 B T 0001 JACKSONVILLE, FL SVMMARY STATEMENT OF DEPICIENCIES I It3 FACii P( cFICIENGYMUST BE PRECSDLD JY FULL RE eJLfiTOPYORLSC IDENTIFYING INFORUATION', I 1% vo u announced B 000 no l~ I I C OCF# 2012000920 1had ~Lili$ tR t1A°ie daflclencles. was Rind to be ih tds - Involuntary in! rnabaii r P 1. The patient sihall be released, Unless he or h i:3 charged with a Crimp, in whl> ris base the patlerlt shall be returned to the custody of a law I enforcement officer, racking I j An i Therapists 11/2011 l I Each Unit has 4.A patitlon for Invoiuntery pleGement shall be filed In the appropriate oou« Bxecu;,ed by he lst,ator when i19rdtrn- r t Is deerned centralized area to place 1 2'e opinion A~ 7 and completion. T' erapists now contact Admissions Deparnnent to inform then, of a patient status change of voluntary to involuntary 5* 4t sand involuntary to voluntary, states, 7-t LS I= hi5(', r~ 02/ 12 08/ i X" 8)DATE V- LE:R IirPRPSeri °aTi)fEa 5I;i AruRE G3S9 _ 11!2011 101120112 requests for second opinion consultations will:an ongoing list to document contacts zo i a j con-tact ;vID to prevent any lye Baker Act procass. 3, The patleftt, unless 69 or she is chargea with a ! crime, shall be asked to give exprest,and Informed consent to piaceryent as a vQll ntary I patlent, and If such consent is given the patient shali ba -+ dItted as a volunL3 , patient- J! j "' Form 31320-0001 iUi i with the Baker Act Frocass new 31 if mn 110. i i 1) iractor of3ehavioral Services educated Therapists how to use tracking log :and the l timeli vdss in coPatactin 3 NO for diserapancias with frJ I i 1/ 2QI1 it ? I LABORATORY S 01RE^ TGR' OR PROVIc7E I i°Director e= Behavioral Services Developed 1 individual tracking logs for units white i( raintaining a facility tracking log re$ tnlerit; f0tolilty 06MI 111201 i cg to facilitate communication discrepancies 1 I 10/2011 I The patient shall be ralemed, 3utjeek to the previsions of sLibparaglapit 1,, icr outpstlert i i 1 j rro,ssF Sa,pe r vi: nor Weekend N pR-therapist now engage lie Ho'ase Supervisor with Weekend Coverage 1 i 08/2QI I t11Cra#~ PS i 164 it i f I Director of Behavioral Services[Designee Educated Weekend PRN Therapists how 11 to use pack ng'og and to engage weekend Withli the 72 hour exn mination period o*, 1 if the 72 hours ends on a weekend of hollavy, no inter ~ than Ile next working day thereafter, one of the rillowing actions must ) e takers, based Uri the " indlvlduall neads of the pstlent: Log to fl j j~ f I developed Facilitate communication With weekend s i wb Ott 394:483, F. npllvme nor.p= S.,Saka,Acx' Enforcement requirements, B 764 Minimum Director of Behavioral Services nd Coverage Tracking a Week.- i~ OCR4 substantiated deficleroles. RiveC Pain's 86havioral Health 110/ 21011& 02/ 12 6/ Nursing Officer/Compliance Cfffice; reviewed and revised policy for involuntary admissions completed complaint aurvays, Februsry2, 2012, and Febrjan-3 14, 2012. pCl3) GOMPLUR DATE GEFIOISNGY) Director ofBenaviora! Services/Chief O2 ( 000920 & 2c012000848 had I CRI OS5REFERENGEDTO THE APPROPRIATE i 2012000843, veers oonduoted at River Point I3ehavloral Health; 8300 Beach I3oui49rsi; Jacksonville, Florida, or r PROVIDER'S PLAN OF Cof, tl4EOT14N SAC 4 0O. I0N ARECTlVRA0j' MOULD $ SE PREFIX TAG INITIAL COMMENTS CC. 3221E and n sheet i of a 0310512012 13:52 Nurung 02/ 2012 23/ 10:51 P. 0031004 0: 09047243797 9043595954 AHCA PAGE 031 04 PRINTED: 02122/412 FORM APPROVED Agency 1,6r Health Care Administration STATEMRNT 01 iL OE!RIOt!' 018 Xi)PROVIDERISUAPIdEWCUA AND PLAN OF CdfQRaCTrdN I DIVER POINT BEHAVIORAL HEALTH B.WING 021941201i2 STREEwTADDRESS, GIN, STATE, ZIP CODE 040 SEACH BLVD RSOUILA ORY OR L 5C 214TfPYiNO TAG E FL 22215 JACKSWAL.LE, SUMMARY STATEMeNTOF 05FtVENGIES H DEFICIENCY MUST BE PRECEDED BY PULL X4)re, PREFIX MMPLETEt1 A. BUILDING G HL104016 NAME OF PROVWER OR SUPPLIER Qt3) DATE SURVEY NSTRUCTION M)MULTIPLF- G{) IDENTIFICATION NUMBER: INP'0r2MArioN) EO PREFIX PROVIDER'S PLAN OF CORRF,OTION xtay I EACH CORRECTIVE ACTION 9140ULD 6a rOMPLrra I TAG EROSSREFERFKOED TO THE APPROE=RIA7 E Wit DEFICIENCY) E 164 Continued From page 1 Director of Behavioral Service least restHctivs necessary; In which case, the treatment ^^ nslstent Lollh the 00.11 gum l 1MPrOV6M8ITi of thO patient's condition shall be j i made avaliable. i I 1 Ch 3K 1-( 453(i), 2This STANDARD Is not rnat as evidenced by Based on reAeW of facility policies and procedures, ravlaw of B RAW Act patient medical records, and interview with facility staff, it was daterrnirled that for 1 Df 5 patient records (02)the facility failed to petition the court for involunil # declined to sign, a placerrisll.when Patient 2 vtilttntary Dgrjg$nt for traatrrlent. Fj l I T;ae ;slrEditlOs Include- l I I E f i Manger i _Review & the madlosl record for I of 5 revealed a patient referred to and patients (# 2) ad pitted to this psyahiatric facility baved an .a Catfloate of Professlonai initiating involuntary Examination submIttEed by a Florida-licensed the up zra AH fl Therapist timely to ensure 02/ 12 03/ tracking when out of the and accurate completion. i 1. ChiefNursing Officer and Medics! Director changed priority from nova-critical i to critical when t in patient declines to si¢; which directs the nurses to voluntary, contact MD immediately when a patient Yak= Ses to iii, 5o MD return, I; complete 1 ovi ion and order 2' opinion or relaases pa•, erit if determined to be safe. 1 Behavioral 02/ 12 10/ I I~ ip I of Services/Compliance educational too;for developed I i nurses to 12 12/,1o _/ Officer be I educated fur above. i Chief Nursing Nurses of i I f Officer/Designee Educate priority change when patient declines to sign in Target 3/ 12 30/to voluntary. Education reach all started 6/ 2/ 1 1 2- PRN Director of Behavioral Services/Director 02/ 2012 20/ nurses Io:" Humar_ Resources update knit s lob descriptions to include st' ITherar, f completing i I fi iI I building is now Chief Nursinaa Officer/Director evaluation by the fsollity psychiatrist occurad ir; t?; 0 silt of 11'22111 ( dictstsd note at `IlWam). Unit Manager Raker Act sfitgn 11121/11 afi,2 the ~2.On2/ revieW of the facsiity s 12, poliq 2/ I I InvoluntaryEvaluation/ " EakerAc't" involuntary Piscamer Admison 1Pracedurei" revealed '" If R is determined Ii Jw3tificatlcr, of", i examination by the Psyci irist that uclient/pation',meets criteria for f to Placement and is unwil nglurable to cgtrsent for treatmant ar7 a voiunatry batsls, the i will hiEi sta proceedings for iave,-, Ci~ responiblt, I i on directly I oversees i O, The reason for the )nvolunatry admission was a diagnoala of Suicidal ldesilDn. The requked psy0latric phys cisn I~- B 164 0ou Ei Baker Act coordinating t; 12 I i Comp' ` a' ce Officer will educate MEC of regarding d ii Staf i=_ the cramunication and the fol ow Involuntary timely y 09/ Medical03/ upon~ j an order is given to allow a patient in voluntarily and declines. To ors i jtin-elyY,lease if safe or i required documentation to gat to court per 6 once Psychiatrist sign invol9urtay cent,.+ 3. Rev;eve of the rnsdsra; recordrECli+^. aied a regulations. i ann 3d GDD9 STATE FORM ems PpWX7:Ifmntruaft cheat 2 0310512012 d'!/' J12012 2~ 10:51 P. 004l004 gAX} 9047243797 13:52 Nursing 9643696064 AHCA 04/04 PAGE PRINTED: 0222212012 FORM APPROVED Aaenay ttrr r Adminl STATEMENT OF DARIQIENCI26 AND PLAN OPr COKReCTfoN on BATE SURVEY 9*) COMPLETED X2)MULTIPLE CONSTRV";TION XI)FR0VIWWSUPFLIER/CLV\ IDENTIFICATION NUMBER: A.BUILDING a WING 021112012 HL104016 NAME OF PFROVIDER OR SuPPoER R" R POINT Oi= HAVIORAL HEALTH p TAG s 8304 BEACH BLVD JACffBOWILLE, FL 32216 SUMMARY STATEMeNr of DeFICIENCIES EACH 0EFI0lENQY MUST BE PRICI JED BY FULL pULATORY OR LSC IDENTIFYING INFORMATION) 7t4)fD PREFrA 6TRE~ TADDRESS, CITY, STATE, ZIP CODE I PS2OV1Dfiit'$PLAN OF CORRECTION ID i EACH CORRECTIVE ACTION SHOULD DE cRIOSSREFERENCED TO THE APPROPRIATE DfiF1CIBN0Y) pREFIx TAQ I 3 8164 Contlnt ed From page 2 6 184 physoisn"s pr res9 note of 11123/11 at 827am which revealed l+ mlunterlly'+. tAat anj may Sign +. Where was documented reviews of this physician note by an RN on 11 11/23/at 1115 am and by an 11/ 241/ at 0215, RN C 1 Director of Behavioral Services now tracks Tr_ voiuntary status timeline as a PI measure of all involantar for deparmert 100% then 20% patients for 3 months if 100% I I ~ j to I QC i 1 paper work completions 3. Doo-rents sent to court 4. Datient is released Director audit to thatthe paperwork to petition Ir: voluntary placemant had not been completed nor (lied with the Qourt, f per the now I complete random monthly ; Starts 03/ 01112 where the patient sign in voluntary are Ongoing managed C policy/regulation. Reporting to (~ I l I I i Ongo~ag 1 l 3 Starts 03/ 12 23/ & ensure cases re fiisal to con.Od f y oluntary and visa versa facility's Consent "" tai Tres?," i to sign"this foM! , i revealed Patient 2 # doollned " thus refusing voluntary placement in the taci?; y. I 1 The r'' Iradicsi record included the proper i paperwork for petitioning for involuntary placement, however, the paperwork had not been ; Initiated by staff or physicianss 1 I Time-line of Involuntary to 4. Review of the 212/12 xa) OOMPLET2 DAT9 record review per month. Reports monthly i 5. t+ 5 at 2prR on itlt~ rvl~ t t 4h ; S~~~ I 1 j I j I i R t I 1 a+ gorrn 3o~ atioas STATE FORM xs~ FPFIXI I if mntinuls*n ocot s of s I M rl FLORIDA ACEWY FOR HMLTH CARED ADMtN 7RAW)N RICK SCOTT ELIZABETH DUDEK Better Health Care for all Floridians GOVERNOR SECRETARY February 22, 2012 Jeanna Risk McIntosh, R.N. Management Specialist River Point Behavioral Health 6300 Beach Boulevard Jacksonville, FL 32216 Re: CCR # 2012000920 and 2012000548 Dear Ms. McIntosh: This letter reports the findings of a state licensure complaint survey and February 14, 2012, by representative(s) of this office. completed on February 2,2012, Attached is your copy of the State (3020)Form, indicating no deficiencies were identified during the survey of CCR#2012000548. Included in your copy of the State (3020)Form, are the deficiencies we found during the complaint 2012000920. survey of CCR# A Plan of Correction (PoC)for the deficiencies must be submitted to this Field Office 2012. You will be notified by telephone or fax if your PoC is found to be acceptable by March 14, or unacceptable. 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 as a first step in providing a webbased htt_ ahca. coin/ Fonns. p m P s ublications/ yflorida. html:// 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 4201. contact us at (904)798- Should surveyor(s). you have any questions, please Sincerely, Robert E.Dickson Field Office Manager Quality Division of Health Assurance j RED/ RF/e Enclosure 7MRZ Jacksonville Field Office 921 N. Davis St.,Bldg. A, Suite 115 Jacksonville, FL 32209 Headquarters 2727 Mahan Drive Tallahassee, FL 32308 http:// myflorida. ahca. c om Phone (904)7984201; Fax (904)359-6054 W