FREEDOM OF INFORMATION REPORT Facility Information Permit: Audit Information RTF-0014 F a c i l i t y N a m e : PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Address: 601 GREGG AVE STE B C i t y / S t a t e / Z i p : FLORENCE, SC 29501-4316 Florence Phone 1: 843-667-0644 Email: GREGORY.JOHNSON@UHSINC.COM                                                                           Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 09 Mar 2017 09:16 AM End Date: 09 Mar 2017 03:32 PM Inspector: Erika Edwards 100.0%                                                                           Question Answer  Overall Score Report Notice Question ID NOTICE01 Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 Report Notice REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate treatment of persons served in this State. It also empowers the Department to require reports and make inspections and investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents, clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of Laws, 1976, as amended. Inspection Information Question ID COMBO-LIC Question Inspection Includes Licensing: Answer YES COMBO-FOOD Inspection Includes Food/Sanitation: NO COMBO-FLSC Inspection Includes Fire & Life Safety: NO ONSITE YES Is this an On-Site Visit? INSP Select the Type of Inspection to be Performed: COMPL-01 Section Team Log Number: Comments RTF Complaint Investigation Section Team Log Number     •   M03017-17 COMPL-03 Reason for Investigation: Comments     •   A complaint (#M03017-17) was received by the Department on 3/7/17. The complaint alleged that: Reason for the Investigation. 1. The facility Administrator neglected patients by denying them proper treatment relevant to behavioral problems that warranted residential placement. S/he changed clinical records/notes which resulted in residents being denied proper treatments or premature discharge. COMPL-04 What is the Source: COMPL-10 Date Agency (DHEC) Notified: Comments Consumer Complaint Date Agency (DHEC) Notified:     •   3/7/17 COMPL-05 Detailed Results of this Investigation: Comments     •   Detailed Results To investigate this complaint, an unannounced on-site visit was made to the facility by (3) representatives of the Department. The investigation consisted of the following: (1). A review of resident records to include care and treatment plans, psychological assessments, physician's notes and observations, consultations, therapy orders and treatment plans, nurses assessments, and medication administration records. (2). Interviews with staff. As a result of this investigation, no violations of Regulation 61-103, Residential Treatment Facilities for Children and Adolescents, were cited. COMPL98 Is this an Unlicensed Facility/Activity Complaint? NO COMPL-06 Has the Initial QI Review Been Completed? NO VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? YES INSP04 Are there any other individuals accompanying the auditor for this visit? Comments YES     •   Perry Davis, Vanessa Stafford Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention   FREEDOM OF INFORMATION REPORT Facility Information Permit: Audit Information RTF-0014 F a c i l i t y N a m e : PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Address: 601 GREGG AVE STE B C i t y / S t a t e / Z i p : FLORENCE, SC 29501-4316 Florence Phone 1: 843-667-0644 Email: GREGORY.JOHNSON@UHSINC.COM                                                                           Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 09 Mar 2017 09:17 AM End Date: 09 Mar 2017 03:31 PM Inspector: Erika Edwards  Overall Score 0.0%                                                                           Audit Level Notes: Email: Rickie.Grant@uhsinc.com Report Notice Question ID NOTICE01 Question Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 Answer Report Notice REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate treatment of persons served in this State. It also empowers the Department to require reports and make inspections and investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents, clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of Laws, 1976, as amended. Administrator's Signature - Plan of Correction Question ID Question Answer SIGN01 PLAN OF CORRECTION - Administrators Certification: I certify that the attached plan of correction describes: (1) the actions taken to correct each cited deficiency, (2) the actions taken to prevent similar recurrences, and (3) the actual or expected completion dates of those actions. POC REQUIRED PRINT NAME:__________________________________________________________________________ TITLE:_______________________________________________________________________________ SIGNATURE:___________________________________________________________________________ DATE:________________________________________ Any violations cited in this report of visit were observed at the time of the inspection. The Administrator submits an electronic plan of correction by visiting the website http://www.scdhec.gov/Health /FHPF/HealthFacilityRegulationsLicensing/HealthcareFacilityLicensing/CorrectionPlan/ and following the instructions online. Or the Administrator returns a copy of this report (original signature required) with description of corrective actions to: SCDHEC, Bureau of Health Facilities Licensing, 2600 Bull St, Columbia, SC, 29201 Your response to this report must be received in our office by close of business (5:00 p.m.) no later than the date listed below: Comments     •   The Plan of Correction (POC) is due 15 days from receipt of this Report of Visit (ROV). Inspection Information Question ID Question Answer COMBO-LIC Inspection Includes Licensing: YES COMBO-FOOD Inspection Includes Food/Sanitation: NO COMBO-FLSC Inspection Includes Fire & Life Safety: NO ONSITE Is this an On-Site Visit? YES INSP Select the Type of Inspection to be Performed: COMPL-01 Section Team Log Number: Comments     •   M03007-17 COMPL-03 Reason for Investigation: Comments     •   A complaint (#M03007-17) was received by the Department on 3/5/17. The complaint alleged that: RTF Complaint Investigation Section Team Log Number Reason for the Investigation. 1. A resident's arm was fractured by a staff member after being put into a CPI hold. 2. Another resident was viciously bitten by another resident. 3. A male and female resident engaged in sexual intercourse on the COMPL-04 What is the Source: COMPL-10 Date Agency (DHEC) Notified: Comments     •   3/5/17 Consumer Complaint Date Agency (DHEC) Notified: COMPL-05 Detailed Results of this Investigation: Comments     •   Detailed Results To investigate this complaint, an unannounced on-site visit was made to the facility by (3) representatives of the Department. The investigation consisted of the following: (1). Resident records to include observation notes, assessments, care and treatment plans, body audit reports, medication administration records, physician's notes and observations, consultations, diagnosis and special precautions. (2). Staffing schedules and assignment sheets. (3). Policies and procedures: The Healthcare Peer Review Occurrence Reporting System policy #RM 102, Staffing to client Ratio policy, Resident Observation policy,, On call Procedures Policy. As a result of this investigation, the following violations of SC Code Ann (Supp. 2016) Regulations 61-103, Residential Treatment Facilities for Children and Adolescents, were cited. COMPL98 Is this an Unlicensed Facility/Activity Complaint? NO COMPL-06 Has the Initial QI Review Been Completed? NO VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? YES INSP04 Are there any other individuals accompanying the auditor for this visit? Comments YES     •   Perry Davis, Vanessa Stafford RTF Regulation Sections 100 - 400 Question ID R-61-103-400.A Question Answer 400.A. Written policies and procedures addressing each section of this regulation regarding resident care, rights, and the operation of the facility shall be developed and implemented, and revised as required in order to accurately reflect actual facility operation. Each facility shall have a clear written statement of its purpose and objectives. This policy shall include a specifically delineated description of the services the facility offers, in order to provide a frame of reference for judging the various aspects of the program. The policy shall also include: (Class II Violation) Comments OUT     •   Written policies and procedures addressing the operation of the facility were not implemented. The Healthcare Peer Review Occurrence Reporting System policy #RM 102 documented the following: The facility utilizes the Corporate approved occurrence report form (Healthcare Peer Review Form- HPR) for reporting occurrences. The Facility utilizes the Probable claim report to report resident occurrences resulting in death, injury, or potential injury to residents, or with the potential for claim. The Risk Manager administers occurrence reporting with all applicable forms as part of the corporate mandated Risk (T.E.R.M)program. Any facility employee or staff member who discovers, is directly involved in, or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer (HPR) form. The HPR is to be completed at the time of the event. The HPR are to be signed by the individual preparing the report. The nurse and shift supervisor on duty at the time of the event is notified of any HPR incident, reviews HPR for completeness, making suggestions or additions as necessary from nursing perspective. The event is documented in the medical record by the person most closely associated with the event and includes a concise statement of the facts of the event, statements are non-judgmental and objective, clinical condition of the patient, names, times of notification of physician, supervisory personnel, family members as necessary. The record shall include intervention and appropriate actions taken for prevention or protection of resident/facility. On the following dates and times, a HPR was not completed or was not available for level II incidents (physical confrontations resulting in minor injury) involving Resident A: a body audit form for Resident A documented that Resident A was involved in a physical altercation with a peer. The resident was bitten on the lower left extremity leaving a bite mark. a body audit form documented Resident A was bitten by a peer on the left arm. The bite mark was a quarter sized and skin was broken. a body audit form documented Resident A was bitten by a peer. A bite mark was noted on the upper left back. a body audit form documented Resident A got into a fight with another peer resulting in a bite mark on right knee. on the left forearm. a body audit form documented that Resident A was bitten by a peer a body audit form documented that Resident A was bitten by a peer. The bite was noted to the right arm with broken skin. There were no interventions documented in Resident A's record, nor appropriate actions taken to prevent or protect the resident. RTF Regulation Sections 500 -1300 Question ID R-61-103-601.B Question Answer 601.B. The licensee shall report each accident and/or incident resulting in unexpected death or serious injury to the next of kin or party responsible for each affected individual at the earliest practicable hour, not to exceed twenty-four (24) hours. The licensee shall notify the Department immediately, not to exceed twenty-four (24) hours, via telephone, email, or facsimile. The licensee shall submit a report of the licensee’s investigation of the accident and/or incident to the Department within five (5) days. Accidents and/or incidents requiring reporting include, but are not limited to: (Class III Violation) Comments OUT     •   The licensee did not submit a report of the licensee’s investigation of a serious accident and/or incident to the Department within five (5) days. An incident report documented that Resident B was involved in an incident with Staff member B in which the staff attempted to keep Resident B from engaging in a confrontation with the other resident. Staff attempted to escort the resident away from the peer and the resident began pulling his/her arm away. "During the point of resistance the staff and the resident heard a popping sound come from the resident's arm". The resident was sent to the hospital and diagnosed with a fractured left elbow. The facility reported/faxed the final investigation to the Department R61-103-1002.A6 1002.A.6. Each resident shall be afforded the following rights: 6. The right to be free from harm, including isolation, excessive medication if applicable, abuse, or neglect; (Class II Violation) Comments     •   OUT (Repeat) Several reports documented that Resident A was not afforded the right to be free from harm. On the following dates and times, body audit forms were completed for level II incidents (physical confrontations resulting in minor injury) involving Resident A: a body audit form documented Resident A was bitten by a peer on the left arm. The bite mark was a quarter sized and skin was broken. a body audit report documented the resident was bitten by a peer. A bite mark was noted on the upper left back. a body audit form documented Resident A got into a fight with another peer resulting in a bite mark on right knee. a body audit report documented that Resident A was hit in the back of the head by another peer. There was redness noted to the area. on the left forearm. a body audit form documented that Resident A was bitten by a peer a body audit form documented Resident A was bitten by a peer. The bite was noted to the right arm with broken skin. Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention 7/20/2018 ReadOnlyPOC PLAN OF CORRECTION REPORTING FORM BUREAU OF HEALTH FACILITIES LICENSING INSPECTION INFORMATION License Number: RTF-0014 Facility Type: HL- Residential Treatment for Children & Adolescents Facility Name: PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Inspection Date: 03/09/2017 Submission Date: 03/28/2017 Type of Inspection: Investigation ADMINISTRATOR'S CERTIFICATION By checking this box, I attest that I am the administrator of the facility/activity and that this plan of correction is accurate. Additionally, I certify that the plan of correction describes the actions taken to correct each cited deficiency, the actions taken to prevent similar recurrences and the actual or expected completion date. Checked Administrator Name: Shannon Marcus E-mail: shannon.marcus@uhsinc.com Phone: (803) 791-9918 RESPONSE TO CITATIONS Section: Was Completion Date Provided? Completion Date (Actual or Expected): 400.A Yes 03/31/2017 Corrective Action: Written policies and procedures with regard to the Healthcare Peer Review Occurrence Reporting System (HPR), policy #RM 102, were not implemented for six specific dates and times for Resident A. Palmetto Pee Dee will implement the following corrective measures: -Staff re-training on HPR documentation will take place during monthly All Staff training no later than 3/31/17. Said training will be provided by the Risk Manager and the Milieu Manager, or his designee. -New Employee Training (NEO) will re-emphasize the HPR documentation training with reflective staff competencies during the next NEO and/or no later than April 7, 2017. HPR documentation training will be provided by the Risk Manager, HPR competencies will serve as verification of internal policy and procedures Palmetto Pee Dee does follow its staff to client ratio policy, Q-15 documentation provides evidence that staff documented in 15 minute increments, patients' location, activity and behaviors. An episode may begin in one location and end in another location during a 15 minute observation timeframe. The staff member(s) who appeared unaware of the patient's whereabouts have been re-educated on Q-15 documentation procedures and appropriate patient observation techniques. Team Leads provide on-going support to all Mental Health Technicians and assist in modeling appropriate observation. The Milieu Manager will review Q15 documentation sheets with the Risk Manager to ensure accuracy with HPR reporting of incidents. Any errors found will be shared in Leadership Team and addressed as necessary. additionally, staff training is provided each month during All Staff meetings with on-going focus on working with population served. http://intraprod/PlanOfCorrection/(X(1)S(jtmmu0nvcrldd0teqmu1mt02))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=14797 1/3 7/20/2018 ReadOnlyPOC Preventive Action: -The Risk Manager or their designee will continue to review HPR documentation daily and provide input during daily Leadership meetings. Any documentation errors found will be corrected and personnel actions taken as warranted. HPR documentation will be included as a Risk Management Performance Indicator and tracked monthly. The program will continue to ensure resident's rights in the following ways: discussions/alerts of resident behaviors during daily shift briefings, discussions alerts of resident behaviors to include elopement risk during daily Rounds meetings, and Special Incident Review meetings as necessary to address high risk behaviors. Human Resources will continue to take appropriate action on any employee found to be non-compliant with internal policy and procedures after having been re-educated on job performance and job expectations. Optional Comments: Response Approved: Yes Section: Was Completion Date Provided? Completion Date (Actual or Expected): 601.B Yes 03/09/2017 Corrective Action: Palmetto Pee Dee did submit an initial report of a serious accident occurring on 2/20/17 within 24 hours of the occurrence, as required. Because the five day timeframe for final reporting fell within a weekend, the internal investigation results were not submitted to the licensing entity until Monday, 2/27/17. The program will ensure that the Risk Manager or their designee, will submit serious occurrence reports within five days to include weekends. Preventive Action: The Risk Manager or their designee will review serious accident an/or incidents daily and report said findings during daily Leadership meetings The Risk Manager or their designee track all serious accidents and/or incidents on a timeline to ensure timeliness of regulatory reporting. Optional Comments: Response Approved: Yes Section: Was Completion Date Provided? Completion Date (Actual or Expected): 1002.A.6 Yes 03/13/2017 Corrective Action: The program will continue to ensure that each resident shall be afforded the right to be free from harm in the following ways: discussion/alerts of resident behaviors during daily shift briefings (led by Team Leads), discussions/alerts of high risk behaviors during daily Rounds meetings, Special Incident Review (Bite Committee) held monthly, or more frequently as needed to address high risk behaviors/incidents. Since implementation of the Bite Committee, biting incidents among residents have been tracked, behavior interventions implemented, and bites reduced by 50% as of February 2017. Preventive Action: -The program will continue on-going tracking of special incidents and utilize treatment interventions as a tool to reduce behaviors. Effectiveness of interventions will be evaluated through performance improvement. -Monthly reporting and on-going discussion of special incidents will continue in both Performance Improvement and Leadership meetings with a focus on on-going incident reduction. -Clinical therapists will continue to provide additional direct care staff training each month during All Staff. Training will focus on the population served and also address deescalation techniques. Optional Comments: Response Approved: Yes LOG INFORMATION SECTION Report of Visit Delivery Date: Plan of Correction Due Date: http://intraprod/PlanOfCorrection/(X(1)S(jtmmu0nvcrldd0teqmu1mt02))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=14797 2/3 7/20/2018 ReadOnlyPOC Date Plan of Correction was Reviewed: 04/03/2017 Reviewed by: L. Sanders, LPN Comments: Plan of Correction Approved: Yes Decision By: L. Sanders, LPN Decision Date: 04/03/2017 Remove POC: UPLOAD DOCUMENTS File Upload Plan of Correction Log Number: MPC03086-17 DHEC Form 0284 (05/2014) http://intraprod/PlanOfCorrection/(X(1)S(jtmmu0nvcrldd0teqmu1mt02))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=14797 3/3   FREEDOM OF INFORMATION REPORT Facility Information Permit: Audit Information RTF-0014 F a c i l i t y N a m e : PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Address: 601 GREGG AVE STE B C i t y / S t a t e / Z i p : FLORENCE, SC 29501-4316 Florence Phone 1: 843-667-0644 Email: GREGORY.JOHNSON@UHSINC.COM                                                                           Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 09 Mar 2017 09:15 AM End Date: 09 Mar 2017 03:30 PM Inspector: Erika Edwards  Overall Score 0.0%                                                                           Audit Level Notes: Email: Rickie.Grant uhsinc.com Report Notice Question ID NOTICE01 Question Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 Answer Report Notice REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate treatment of persons served in this State. It also empowers the Department to require reports and make inspections and investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents, clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of Laws, 1976, as amended. Administrator's Signature - Plan of Correction Question ID Question Answer SIGN01 PLAN OF CORRECTION - Administrators Certification: I certify that the attached plan of correction describes: (1) the actions taken to correct each cited deficiency, (2) the actions taken to prevent similar recurrences, and (3) the actual or expected completion dates of those actions. POC REQUIRED PRINT NAME:__________________________________________________________________________ TITLE:_______________________________________________________________________________ SIGNATURE:___________________________________________________________________________ DATE:________________________________________ Any violations cited in this report of visit were observed at the time of the inspection. The Administrator submits an electronic plan of correction by visiting the website http://www.scdhec.gov/Health /FHPF/HealthFacilityRegulationsLicensing/HealthcareFacilityLicensing/CorrectionPlan/ and following the instructions online. Or the Administrator returns a copy of this report (original signature required) with description of corrective actions to: SCDHEC, Bureau of Health Facilities Licensing, 2600 Bull St, Columbia, SC, 29201 Your response to this report must be received in our office by close of business (5:00 p.m.) no later than the date listed below: Comments     •   The Plan of Correction (POC) is due 15 days from receipt of this Report of Visit (ROV). Inspection Information Question ID COMBO-LIC Question Inspection Includes Licensing: Answer YES COMBO-FOOD Inspection Includes Food/Sanitation: NO COMBO-FLSC Inspection Includes Fire & Life Safety: NO ONSITE Is this an On-Site Visit? YES INSP Select the Type of Inspection to be Performed: COMPL-01 Section Team Log Number: Comments     •   M02012-17 COMPL-03 Reason for Investigation: Comments     •   A complaint (#M02012-17) was received by the Department on 2/7/17. The complaint alleged that: RTF Complaint Investigation Section Team Log Number Reason for the Investigation. 1. There is lack of supervision in the facility. One resident was missing for an hour and was later found crawling around in the ceiling after almost falling through into another room. Another resident was found with a lighter and threatened to the burn the building down. Two residents were found in the closet kissing. 2. A resident was given the wrong medications on After the resident questioned the medications, the nurse gave the resident a second dose and asked the resident if they were his/hers. 3. There was no nurse present in the facility on 3rd shift on COMPL-04 What is the Source: Consumer Complaint COMPL-10 Date Agency (DHEC) Notified: Comments Date Agency (DHEC) Notified:     •   2/7/17 COMPL-05 Detailed Results of this Investigation: Comments     •   Detailed Results To investigate this complaint, an unannounced on-site visit was made to the facility by (3) representatives of the Department. The investigation consisted of the following: (1). Resident records to include observation notes, assessments, care and treatment plans, body audit reports, medication administration records, physician's notes and observations, consultations, diagnosis and special precautions. (2). Staffing schedules and assignment sheets. (3). Policies and procedures: The Healthcare Peer Review Occurrence Reporting System policy #RM 102, Staffing to client Ratio policy, Resident Observation policy,, On call Procedures Policy. As a result of this investigation, the following violations of SC Code Ann (Supp. 2016) Regulations 61-103, Residential Treatment Facilities for Children and Adolescents, were cited. COMPL98 Is this an Unlicensed Facility/Activity Complaint? NO COMPL-06 Has the Initial QI Review Been Completed? NO VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? YES INSP04 Are there any other individuals accompanying the auditor for this visit? Comments YES     •   Perry Davis, Vanessa Stafford RTF Regulation Sections 100 - 400 Question ID Question R-61-103-400.A 400.A. Written policies and procedures addressing each section of this regulation regarding resident care, rights, and the operation of the facility shall be developed and implemented, and revised as required in order to accurately reflect actual facility operation. Each facility shall have a clear written statement of its purpose and objectives. This policy shall include a specifically delineated description of the services the facility offers, in order to provide a frame of reference for judging the various aspects of the program. The policy shall also include: (Class II Violation) Comments     •   The facility staff did not follow it's staff to client ratio policy. The policy documented that Residents shall remain in sight and sound observation range of staff at all times. Staff shall conduct periodic visual welfare checks of all residents at intervals not to exceed every 15 minutes. (1). An HPR incident report dated documented the following: "While in the day room, Patient A and B ran down the hallway. When staff found the patients (residents) they were in the laundry room kissing and touching on each other". According to staff, the laundry room door was supposed to be locked and secured at all times while not in use. However, Patient A was assigned to the unit, and Patient B was assigned to the unit. According to staff, Patient B was observed with patient A and proceeded to run down the unit hallway and into a secured/locked laundry room. Two different staff members were assigned to Patients A and B because they were on two different units. The Staff assigned to the Unit found the patients in the laundry room. The Answer OUT (Repeat) staff assigned to the unit was not aware of the patient's whereabouts. Therefore, staff did not ensure that patients assigned to them remained in sight and sound observation range at all times. (2). An HPR incident report dated documented the following: "Staff was exiting back door when she noticed Patient A on the recreation field climbing the fence. Staff processed with Patient A and transitioned to team lead and explained to him what happened and team lead returned patient A back to his/her unit". Patient A is assigned to the unit. The staff monitoring sheet documented the patient was on Q-15 minute observations. At the staff member completing the observation sheet documented that the patient was in the hallway pacing/walking while refusing directive. Staff member A was not aware that Patient A had gone outside the unit and onto the Recreation field. Therefore, staff on the unit did not ensure that patients assigned to them remained in sight and sound observation range at all times, and did not conduct periodic visual welfare checks of all residents at intervals not to exceed every 15 minutes, and did not correctly document the patient monitoring sheet. (Note: An incident report log documented that Patient A was found in an unauthorized area on three other occasions ) Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention 7/20/2018 ReadOnlyPOC PLAN OF CORRECTION REPORTING FORM BUREAU OF HEALTH FACILITIES LICENSING INSPECTION INFORMATION License Number: RTF-0014 Facility Type: HL- Residential Treatment for Children & Adolescents Facility Name: PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Inspection Date: 03/09/2017 Submission Date: 04/06/2017 Type of Inspection: Investigation ADMINISTRATOR'S CERTIFICATION By checking this box, I attest that I am the administrator of the facility/activity and that this plan of correction is accurate. Additionally, I certify that the plan of correction describes the actions taken to correct each cited deficiency, the actions taken to prevent similar recurrences and the actual or expected completion date. Checked Administrator Name: Shannon Marcus E-mail: shannon.marcus@uhsinc.com Phone: (803) 791-9918 RESPONSE TO CITATIONS Section: Was Completion Date Provided? Completion Date (Actual or Expected): 400.A Yes 03/13/2017 Corrective Action: Palmetto Pee Dee does follow its staff to client ratio policy. Q-15 documentation provides evidence that staff document in 15 minute increments, patients' location, activity and behaviors. An episode may begin in one location and end in another location during a 15 minute observation timeframe. The staff member(s) who appeared unaware of the patient's whereabouts have been re-educated on Q-15 documentation procedures and appropriate patient observation techniques. Team Leads provide on-going support to all Mental Health Technician's and assist in modeling appropriate observation techniques. The Milieu Manager will review Q-15 documentation sheets with the Risk Manager to ensure accuracy with HPR reporting of incidents. Any errors found will be shared in Leadership Team and addressed as necessary. Additionally, staff training is provided each month during All Staff meetings with an on-going focus on working with the population served. Preventive Action: The program will continue to ensure resident's rights in the following ways: discussions/alerts of resident behaviors during daily shift briefings (led by Team Leads), discussions alerts of residents behaviors to include elopement risk during daily Rounds meetings, and Special Incident Review meetings as necessary to address high risk behaviors. Human Resources will continue to take appropriate action on any employee found to be non-compliant with internal policy and procedures after having been re-eecuated on job performance and job expectations. http://intraprod/PlanOfCorrection/(X(1)S(mobtka4gwxmpn2z0crpsm5y2))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=15167 1/2 7/20/2018 ReadOnlyPOC Optional Comments: Response Approved: Yes LOG INFORMATION SECTION Report of Visit Delivery Date: 3/14/2017 Plan of Correction Due Date: 3/29/2017 Date Plan of Correction was Reviewed: 05/04/2017 Reviewed by: AS Comments: Plan of Correction Approved: Yes Decision By: AS Decision Date: Remove POC: UPLOAD DOCUMENTS File Upload Plan of Correction Log Number: MPC04011-17 DHEC Form 0284 (05/2014) http://intraprod/PlanOfCorrection/(X(1)S(mobtka4gwxmpn2z0crpsm5y2))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=15167 2/2