hec 5€ Crl}rtrfcil r, Hdrtth Elll nillCtrlac, [0.6r INSPEGTION RESULTS Audlt lnformatlon Faclllty lnformatlon Audlt Name: RTF ROV 20151020 rlps: L07 lnvestigation Address: Start Date: End Date: 13 Dec 2016 06:30 AM 601 GREGG AVE STE B CitylstatelZlp: FLORENCE, SG 29501 *431 6 Flotence lncpector: Erika Edwards 1; Emall: &43€67{644 Score: O.0o/o Pennlt Number: RTF-0014 Faelllty Name: Phone PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER 13 Dec 2016 02:30 PM GREGORY.JOHNSON@UHSINC'COM Contact Name: LAKESHIA COAKLEY Contact Emall: null Contact Phone: 803-34&2183 Overall Score 0.0% Report Notice Questlon Anawer Psrcsnt f,eport Notice Bureau of Health Faeilities Licensing 2600 BullSt Columbia SC 29201-1708 REPORT NOTICE ll apdcaHe, bls Report ot \ftslt lnc&rde3 a &tafled de$rldoft of lhe conditims ordud ot pradixs hat Utef! furnd o bc ln vlolaton oirequirunents ttis lnspedbn or tmrediga8on b mt to be cmstued as a clpcl of every corddon hal ttEy erist, ol nor does tl relhw the llcansee (ormer) from tlre need lo nreet a[ app[caHe stardards. regulations *rd lars, The Soufi Carofflr Code Laws requlres lhls Departrnent-to esta'tlstr anO enforce baslc slandsrds ftr the llcansrrc (permi[hg), rnaintcnarrce' and operauon ol h€allh hc1itles and seMces lo ensure tre safe ard adequate featmefll ol persons served ln 0rts Shte. lt also emporvers &s Depstn€nt to reguire repqts arrd rnake impeclions and lrruestbalions as consldated necessary. Fufihenrua he Code auhuizet he Depa.W€nl (anprg otter reasons)' U *iy, arrsienO, or revdte lirnses (permits) or lo ass€ss a nnnetary penalty agdnd a person or EdHy 6r dUafirrg a pmvlslon of lau or deparlnerdal regndations o condrd or pradices dekkncntal lo tre feaBr ot safely of pa0erils, IesHeils, ve cfe.ars, or impoyees of a facfrty or Eewice. lf apdnafie to the Vpe of eporl bekrg made, he slgrraire ot he adivity reftes$tat nOUes tlraiall of fie iterns cjled were revicwea dudng tE ex'rtdbnrsCoo. lf hls Repofl of Vlslt ls reqr*ed by reguhlhfl to be rude Is equired as arraitable ln a consplcuous place in a public area wihln fre hciity reda&n of he rumes of fiose lndMduds tn lhe ,epod prwkledbySeclions,t4-7-310and4,1-7-3t5offieS.C,CodoolLaun 1978'*4nenffi, Totals Administrator's Signature - Plan of Correction Quegtlon PLAN OF CORRECTION - Admlnistrators Certlf cation: I ceril0 lhat lhe altached plan ol coneclion describes (1) tl€ acilons taken lo corred each dled defidency, (2) U1e acilons laken lo prevenl simibr retlnerrces, and dates of those adions. (3)he adual or & lrnswer POC REOUIRED Porcont I + Ary vlobthns llds report of vM were obseled d lhe time ol lfie hspedi:n ]ffp,rtvw'w sc!trleagpv'Hedh The Affinigtralor g$m*s an elec{rcnb plan olcqrredkrby vi8[rngtEwery$e hE lGlructhns onllne' GHpFiHsdtrFadlityReguhtbnslice-ndr*r"*rhcar.f*iitvlbensrrgEotledtofiPlaril end htrovliE Or lhe Adminlstrator tBlums a copy of lhis lBpqt (or{Slnal signstute t?quhed} SCD}IEC. Burear otHeatfi Faoiltis Lixnslng. 2600 Btd YOrn r*ponse b thls reporl mrst be reeh,ed ln or wfi &sc'idhn of corlectivo scljons lo: St CdrmHa' Se 2g20r ofrice by dose of bus&ress (5:00 p'm') no lsla th3n h€ datE fisted belo": Commentg Tha Plan ol canection is due I 5 days lrom receipt of lhis Repod of visit tRov) ' .(POC) ffi Totale lnspection lnformation Quegtlon lnspection lncludes Licensing YES NO lnspection lncludes Food/Sanltation NO lnspection lncludes Fire & Lile Salety YES ls this an On-Site Visit? RTF ComPlaint Select lhe Type ol lnspection to be Performed lnvastigation Sgction Team Log Number Section Team Log Number: Commants . M12017-16 Reason for Beason for lnvestigation: Comments complalne recelved by lhe Bureau camPlalnt alleged lhe tollowlng: A the lnvastigation. of Health Facttttles Llcenstng was lnvestlEated' rhe Slha now weiglts weighing _132lbs clienl/residenl was admiled lo the focility on tha tast 4 months within facitity al lha clienls olher by 96.6rbs. Tha clienthas been bitten 4-5 times Srhe is always visibly dirty and lilthy ' A Gonsumer Complaint What is the Source: Date Agency (OHEC) Notified: Commsntg , Date Agency (DHEC) Notified: 12/7/16 Detailed Results of this lnvestigation: Detailed Results CommentE made to the faclltly by (2) To lnvestlgate thts comptatnt, an unanno,rnced on.slte vlsll was ol the tollowlng: of the 6iiiii""t. The lnvestlsatloa conslsled ,ipr.""it Aues observalions' medicatton lndivklual lrealmenl ptans (ITP), weekty nurang summatiss, 1'-mlnuta sheets, unlt slat?assignmanl adminislnlionrecords, ctiicaitassessrrer?ls, dietaryassessmanfs, procedures' body policies and roparls, and togs coosus inctuding rasidenl Jiagnosis, incidant/accidenl ot aaiy tiving logs, and inleruiews with the slaff and Rasldent A audit reporls, ""tiuiti* 61,-103' Residential Tteatmanl this investigalion, tha following vialations of Regutation Facitilies for Chitdran lnd Adolsscenls, wara cited' As a resur, of ls this an Unllcensed FacilitylActivity Complaint? NO ,/rt/aor/ PLAN OF CORRECTION REPORTING FORM BUREAU OF HEALTH FACILITIES LICENSING \iol'r*t a*wrw$t *t ,twld\ ffd Efr{r*ffi**l{MW *n. D/U ,lh/ INSPECTION INFORMATION License Numben RTF-0014 Facility Type: HL- Residential Treatment for Children & Adolescents Facility Name: PALMETTo PEE DEE RESIDENTIAL TREATMENT CENTER Inspection Date: 121',t312016 Submission Date: 0110412017 Type of lnspection: lnvestigation ADM I NISTRATOR'S CERTIFICATION By checking this box, t attest that I am the administrator of the facility/activity and that this plan of correction is accurate. Additionatty, I certify that the plan of corection describes the actions taken to conect each cited deficiency, the actions taken to prevent similar recurences and the actual or expected completion date. Checked Administrator Name: Lakeshia Coakley E-mail: lakesh ia.coakley@uhsinc.com Phone: (843) 667-0644 RESPONSE TO CITATIONS Section: Was Gompletion Date Provided? Completion Date (Actual or Expected) 400.A Yes 0111812017 Corrective Action: By submitting this plan of Correction, Palmetto Pee Dee does not agree that the facts alleged are true or admit it violated the rules. Policy #NSG 27 has been revised and staff re-trained. After an initial screening by the nurse, new residents receive a nutritional consult within 2 weeks from the date of admission. Special diets will be ordered by the physician. lt is the responsibility of the Director of Nursing (DON) to ensure communication to and implementation by the dietary staff. Preventive Action: The DON will review Dietary Communication forms on a monthly basis and make any necessary corrections and/or provide staff training, as needed. Optiona! Gomments: I sent by email to the facility stating we do not support the disclaimer at the top. This attached to the Steton packet. L. Sanders, LPN Response Approved: Yes Seqtion: Was Complotion Date Provided? Completlon Date (Actual orExpected): 504.B Yes 1213012016 Comective Action: The program will continue to meet Medicaid and DHEC standards by providing sufficient supervision and staffing at all times. Residents are not maintained in one place throughout the day. Residents attend class, participate in recreational activities directed by the Rec Therapist, an( transition to/from other portions of the program (i.e individual and group therapy, consulls, etc.). Additional activities have also been implemented to ensure therapeutic engagement. Preventive Action: lncidents are tracked and monitored. Team Leads, the Milieu Manager and Nursing are available for staffing assistance. lf incidenls are not decreased, Risk lranagement and Leadership will increase unit activities and revisit daily schedules. Optional Comments: Response Appmved: No Section: 504.C Was Gompletion Date Provided? Completion Date (Actual or Expected): Yes 1213012016 Con€ctive Action: Documentation for the date in question (10/8/16) was provided, however the shift was not circled. The Milieu Manager will provide documentation training to the Team Leads, and reviewfor compliance weekly. Preventive Action: The Milieu Manager will ensure Shifl Report documentation compliance by routine auditing and provide staff re-training as necossary Shift reports will be maintained on site for a period of no less than 2 years with overflow stored/managed by off site storage company. Any off site records can be retrieved within 24 hours. Optional Commenls: Responae Approved: No Section: Was Complellon Date Provided? Complstion Date (Actual or Expected): 704.4 Yes O1l18l2O'17 Co]Iective Action: A new treatment plan format will be implemented mid-January, which will prompt review of nutritional needs. Clinical therapist will be trained o the new format. The program will ensure rcgular BMI documentation for all residents. The DON, or designee, will address weight gains/loss during each treatment team. PlBventive Action: Clinical and nursing audits will be conducled on a routine basis by the Clinical Director and the DON, or their respective designee(s). The DOI or designee, will review residents Bl\41's and ensure that findings are addressed in trealment leam. Optional Comments: Response Approved: Yes Section: Was Completion Date PTovided? Completion Dats (Actual or E)Qected): 704.C.1 Yes O1I18DO17 corective Action: The written policy and procedure #CS045 has been revised to address requirements and arrangements for visits by or to physicians or other authorized healthcare providers on the trealment plan. Clinical therapist will be trained on this treatment plan revision by '1118/2017. Proventivo Action; Clinical audits will be conducted by the Clinical Director to ensure implementation Optlonal Comments: Response Approved: Yes Section: 704.C.2 Was Completion Date Provided? Completion Date (Actual or Expected); Yes 0111812017 Corective Action: The written policy and procedure #CS045 has been revised to better address recreational and social activities which are suitable, desirable, and important to the well-being ofthe resident. Clinical therapist will be tIained on this treatment plan revision by l/18/2017. Preventive Action: Clinical audils will be conductsd by the Clinical Director to ensure implementation. Oplional Comments: RGsponse Approved Yes Section: 704.C.3 l/t aa Completion Dat€ Ptovided? Completion Date (Actual or Expected): Yes 01118120'17 Con€ctive Aclion: The written policy and procedure #CS045 has been revised to better address nutritional needs of the residenl. Clinical therapist will be trained on this treatment plan revision by 1/18/2017. Preventive Action: Clinical audits will be conducted by the Clinical Director to ensure implementation. Optional Commsnts: Response Approved: Yes Section: Was Completion Date Pmvided? Completlon Date (Actual or Expected): 704.D Yes 1212212016 Co]fective Action: Both existing treatment plans and the newly revised plan(s) delineate staff responsibilities for each intervention by position (i.e. clinical therapist, mental health tech, nurse, etc.). Preventive Action: Clinical audils will be conducted by the Clinical Director to ensure that correct staff position meets the intervention. (i.e. toileting=MHT with nursing oversight). Optional Comments: R€sponse Apprcved: Yes Section: was Completlon Date Prcvided? Completion Date (Actual or Expected): 902.F.1 Yes 0111812017 Coractive Action: The program's 20l6 written Plan of Care in the Clinical Manual documents the service array and clinical components of the residenfs stay in treatment. This has been revised for 2017 to better address the facility's philosophy with regards to group size, composition and supervision. Preventive Aclion: The program will continue to monitor incidents to ensure adequate staffing for various groups and activities. Staff training is on-going. lf incidenls are not reduced, scheduling will be revisited. Team Leads and Milieu Manager are always available for assistance. Optional Comments: Response Approved: No Section: Was Completion Date Provlded? Completlon Date (Actual or Expected): 1002.A.6 Yes 1213012016 Co]Iective Action: The program continues to ensure thal each resident be afforded the right lo be free from harm, including isolation, excessive medication if applicable, abuse or neglect. Staffing meets all Medicaid and DHEC standards and additional staff (i.e. Team Leads, Milieu Manager, Leadership) are available as needed. The program will continue to monitor incidents and provide support to staff as necessary. Preventlve Action: lncidents are hacked monthly and addressed in Performance lmprovement and Leadership. Risk Managemenl continue to provide oversight and guidance with respect to scheduling, daily activities and incident reduclion. Staff training is on-going and camera's reviewed for lraining purposes and to ensure complaince to standards. Optional Comrrents: Response Approved: No LOG INFORMATION SECTION Report of Vl3lt Dellvery Date: 12121t2016 Plan of Conection Due Dats: 1t512017 Date Plan of Conection was Reviewed: 01110120't7 Reviewed by: L. Sanders, LPN Commenls: Plan of Comctlon Approv€d: No Deciaion By: L. Sanders, LPN Decision Date: 0111112017 Remove POC: UPLOAD DOCUMENTS File upload Plan of Correction Log Number: MPCO1014-17 DHEC Form 0284 (0512014) DHEC ll..ldr 2600 BULL STREET, Colultutit, SC, 2920t s{s4370 FAx (s03) 545-4212 E-il,rtt" EEEt@dhss.ssggy oFrrcE (803) NOTICE: lnformation on the audit inspection form will tnspection >ate: 121 ,6 PLAI\I OF CORRECTION Bunr.lu Or Heelru Facturtes Ltcexstxc ffiffiffi &rd Grdtr. ll.lsr,Frt.{ dfrmDFtlddik.{ t/-/ 0/ I 13n416 be needed to assist you in Today's Date: 12f27 l20l 6 this form. License Prefix: RlnF Suffix #: 14 Typeoflnspection: 107 INVESTIGATION Name of Facility/Activity: Palmetto Pee Dee Behavioral Health ffi By checking this box, I attest that I am the adminisnator of the facilitylactiviry and that this plan of correction is accurate. Additionally, I certi$ that the plan of conection describes the actions laken to corect each cited deficiency. the actions taken to prevent similar recuffences and the actual or expected completion date. Administrators Certiticatirn, Administrator Name: Lakeshia Coakley E-mail: lakeshia.coakley@uhsinc.com Phone: 8436670644 RESPONSE TO CITATIONS lll8l20l7 Y sccrion:4oo.A. . th1ilffffi;i Co;qection, Palmetto Pee Dee does not agree that the facts alleged are true or adrnit it violated the rulesl'Policy #NSG 27 has been revised and staff re-trained. After an initial screening by the nurse, new residents receive a nutritional consult within 2 weeks from the date of admission. Special diets will be ordered by the physician. lt is the responsibility of the Director of Nursing (DON) to ensure communication to and implementation by the dietary staff. prevenrive Acrion: The DON will review Dietary Communication forms on a monthly basis and make any necessary corrections and/or provide staff trainlng, as needed correcrive ecttonllBy 1U3A/2O16 $ , '1il;'"'ffi/orwtu{, Completion Date (Actual or Expected) sufniiiting Completion Date (Actual or Expected) Section:504,8. to meet Medicaid and DHEC standards by providing sufficient supervision and staffing at alltimes. Residents are not maintained in one place throughout the day. Residents attend class, participate in recreational activities directed by the Rec Therapist, & transition to/from other portions of the program (i.e. individual & group therapy, consults,etc). Additional activities have also been implemented to ensure therapeutic engagement. prevenrive Acrion: lncidents are tracked and monitored. Team Leads,the Milieu Manager & Nursing are availabte for staffing assistance. lf incidents are not decreased, Risk Management and Leadership will increase unit activities & revisit daily schedules. Cone*ive Action: The program will continue lzn0ftA16 Comptetion Date (Actual or Expected) )9 Section:504.C. correcrive Acrion: Documentation for the date in question (10/8/16) vvas provided, however the shift was d- not circled. The Mitieu Manager will provide docurnentation training to the Team Leads, and review for compliance weekly. prevenrive Acrion: The Milieu Manager will ensure Shift Report documentation compliance by routine auditing and provide staff re-training as necessary. Shift reports will be maintained on site for a period of no less than 2 years with overflow stored/managed by off site storage company. Any off site records can be retrived within 24 hours. $ lllSnAlT Complction Date (Actual or Expccted) Section:704.4. A new treatment plan forrnat will be implented mid-January, which will prompt review of nutritional needs. Clinicaltherapists will be trained on the new format. The program willensure regular BMI documentation for all residents. The DON, or desginee, will address weight gainslloss during each treatment team. corrective Acrion: DHEC Form 0949 (03/2014) [Records Retention 163271 Action: Clinical and nursing audits will be conducted on a routine basis by the Clinical Prevenrive Director and the DON, or their respective desginee(r s). The DON or designee, will review residents BMI's and ensure that findings are addressed in treatment team. 7 Completion Section:704.C.1 I / I 81201 ,z n Date (Actual or Expected) The written policy and procedure #CS045 has been revised to address requirements and anangements for visits by or to physicians or other authorized healthcare providers on the treatment plan. Clinicaltherapists will be trained on this treatment plan revision by 0U18n017. Prevenrive Action: Clinical audits will be conducted by the Clinical Director to ensure implementation conecrive Action: li l8/2017 Completion Date (Actualor Expected) \b Section:7A4.C.2 Corrective Action: The written policy and procedure #CS045 has been revised to better address recreational and socia! activities which are suitable, desireable, and important to the well-being of the resident. Clinical therapists will be trained on this treatment plan revision by 0111812017. Prevenrive Action: Clinical audits will be conducted by the Clinical Director to ensure implementation. l/l8D0l7 V r Completion Date (Actual or Expected) Section:704.C.3 The written policy and procedure #CS045 has been revised to better address nutritional needs of the resident. Clinical therapists will be trained on this treatment plan revision by 01t1u2a17. Prevenrive Action: Clinical audits will be conducted by the Clinical Director to ensure implementation. Conective Action: 12122n416 Completion Date (Actual or Expected) Section:704.D. Both existing treatment plans and the newly revised plan(s) delineate staff responsibilites for each intervention by position (i.e. clinicaltherapist, mental health tech, nurse, etc.). prevenrive Action: Clinical audits will be conducted by the Clinical Director to ensure that correct staff position meets the intervention (i. e. toileting = MHT with nursing oversight). conecrive Acrion: You can download th ls form as many times 2 Page Number Send completed 8S needed tn ordcr to answer al itations. ls this a continuation page? Yes x No (if you answered Yes to the question above) form by e-mail at BHFL@dhec.sg.gov or by mail to SCDHEC, BHFL, 2600 Bull St, Columbia, SC' 29201 INSTRUCTIONS: DHEC FORM 0275 PLAN OF CORRECTION BURETUOF HEALTI Faclurtss LICENSING (0ltrL) PURPOSE: Provide facilities or services with a form to respond to citations afler an inspection was conducted by the DepartmenL EXPLANATION: This form is used by facilities or activities, licensed by the Department through the Bureau of Health Facilities Licensing, to respond to citations made from an inspection. Item bv ltem Insnuctions: l. tnspection Date: From information on the inspection audit, €nter the date the inspection was conducted at the facility. ?. Today's Date: Enter the date you are completing this form. 3, License Prefix & Suffix: Frorn information on the inspection audit, choose the license prefix and then enter the suflix number (this is the license number that appears on your license)' DHEC Fom 0949 (032014) [Rccords Rctcnlion 163271 PLAN OT CORRECTION BuRelu Or HslLrH Flctuurs Llcsxstxc fu_fo'# h.h 2600 BULL STRf,sr, COLUMBIA, sc,29201 (803) orFrcE 545-4370 F^x (E03) 5434212 E-lrAil- BHFL@dhec.sc.s,ov iirrfirr lkF rD6nr{ tltddr Bt gda,h6.rird (rnH.l NOTICE: lnformation on the audit inspection form willbe needed lo assist you in completing this form. Inspection Date: 121 1 3/2A16 Today's Darc 12127nA16 License Prefix: rtIF Suflix fl: 14 Type of lnspectioa: L07 INVESTIGATION Name of Faciliry/Activity: Palmetto Pee Dee Behavioral Health Administrators Certilicatioo, [! By chccking this box, I attest that I am the administrator of the faciliry/activity and that this plan ofcorrection is accurate. Additionally, I certi$ that lhe plan ofcorrection describes the actions taken to correct each cited def[ciency, the actions taken Io prevent similar recurrences and the actual or expected completion date, AdministratorName: Lakeshia Coakley E-mail: lakeshia.coakley@uhsinc.com Phone: 8436670644 RESPONSE TO CITATIONS 1 $f $ $ 11812017 Comptetion Date (Actual or Expected) Section: 9O2.F.1 The program's 2016 written Plan of Care in the Clinical Manual documents the service and array clinical components of the resident's stay in treatrnent. This has been revised for 2417 b better address the facility's phalosophy with regard to group size, composition and supervision. preventive Acrion: The program will continue to monitor incidents to ensure adequate staffing for various groups and activities. Staff training is on-going. lf incidents are not reduced, scheduling will be revisited. Team Leads and Milieu Manager are always available for assistance. Correcrive Acrion: 12130nA16 Completion Date (Actual or Expected) Section: 1002.A.6 correcrive Acrion: The program continues to ensure that each resident be atforded the right to be free from harm, including isolation, excessive medication if applicable, abuse or neglect. Staffing meets all Medicaid and DHEC standards and additonal staff (i.e. Team Leads, Nurse, Milieu Manager, Leadership) are available as needed. The program wil! continue to monilor incidents and provide support to staff as necessary. prevenrive Acrion: lncidents are tracked monthly and addressed in Performance lmprovement and Leadership. Risk Managernent continues to provide oversight and guidance with respect to scheduling, daily activities and incident reduction. Staff training is ongoing and camera's reviewed for training purposes & to ensure compliance to standards. Completion Date (Actual or Expected) Section: Corrcctive Action: Prcventive Action: Completion Date (Actual or Expected) Section: Conective Action: Preventive Action: Cornpletion Date (Actual or Expected) Section: Corrective Action: Preventive Action: Completion Date (Actual or Expectcd) Section: Corrective Action: DHEC Form 0949 (0312014) [Rccords Rctcntion I 632?! Unacceptable POC Sanders, Lorie D. Wed 1/1 1/2017 1:18 ?Yi to: lakeshia.coakley@uhsinc.com < lakeshia.coakley@uhsinc.com >; Bcc:Smith, Angie ; Kelly, Shelly B. ; Thompson, Gwendolyn ; English, Terry ; tmportance: E 1 High attachments {164 KB) lnvestigation Palmetto Pee Dee.pdf; Ms. Coakley, Thank you for sending in your Plan of Correction for Palmetto Pee Dee Residential Treatment Center. This was an investigation MI20t7-16 report of visit dated December L3,20L6.As a result of our review, the Department has determined that the Facility's Plan of Correction does not adequately address a corrective and/or preventive action for the cited violations stated below. Therefore, the Plan of Correction is not acceptable due to the following reasons: 400.A : The Department does not accept the disclaimer "By submitting this Plan of Correction, Palmetto Pee Dee does not agree that the facts alleged are true or admit it violated the rules." We did accept the corrective action and the preventive action that you had listed nothing else needs to be addressed with this violation. 504.& Your response to the correction action is not accepted, and your preventative action does not state how this violation will be preventive in the future. SOC&fhe response to the corrective action is accepted, however your response to the preventative action is not accepted. 902.F.1: The response to the corrective action is accepted, however your response to the preventative action is not accepted. 1002.A.5: Your response to the correction action is not accepted, and your preventative action does not state how this violation will be preventive in the future. Palmetto Pee Dee Residential Treatment Facility must complete an amended Plan of Correction addressing the above deficiencies. The amended Plan of Correction must be received by the Department on or before Monday January 16,2016 or a citation by mailwill be sent. Please submit this Plan of Correction or our website using the below link httn://www.scdhec.soviFlealIh/FHPF/HealthFaciliwResulationsLicensins/HealthcareFacilitvl-icensins/Correction Plan Re: unacceptable POC Sanders, Lorie D. Wed 1/1112017 3:41 PM To:Buhl, Linda ; I apologize for the error. It should be 504.8 The correction action was not accepted, and the preventive action does nofstate how this violation will be preventive in the future. 504.C The preventive action is not accepted. Thanks for bring this to my attention Lorie D.Sanders, LPN Complarint Departrnent South Carolina Departrnent of Health and Environmental Control Bureau of Heal& Facilities Licensing Columbia Mills Office: 8oS-S4S-424o Fax: 8o3-545-4zrz "This email is intended only forthe use of t{re individual or entity to mhich it is addressed and may contain inforrnation which is privileged and confrdential. If the reader of this email is not the intended recipient, you ane hereby notified that any disdosure, distribution, or copying of this inforrnation is strictly prohibited. If you received this email in error, please notify the sender immediately by reply." From: Buhl, Linda Sent: Wednesday, January 7L,2Ot7 2:55:39 PM To: Sanders, Lorie D. Cc: Coakley, Lakeshia Subject: unacceptable POC Ms. Sanders - in reading your email regarding our POC, it references "5A4.N' lt goes on to say the response is not accepted and on the next line it states it is accepted, but the preventative action is not. don't see a 504 A on the report. Please clarify as this applies to two separate and distinct citations (l also left a message on your telephone). Thanking you in advance, I Linda Buhl Director of Health lnformation Services Palmetto Pee Dee Behavioral Health 6018 Gregg Avenue Florence, SC 29501 (8431667-0644 of Delaware, lnc. Confidentiality Notice: This e-mail message, including any attachments, is forthe sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review use, disclosure or distribution of thls information is prohibited, and may be punishable by law. lf this was sent to you in error, please notify the sender by reply e-mail and destroy all copies of the original UHS message. Any questions or concerns please let us know. Lorie D.Sanders, LPN Complaint Depolrfinent South Carolina Departrnent of Health and Environmental Cnnbol Bureau of Health Facilities Licensing Columbia Mills Office: 8oB-S4S-424o Fax: 8o3-545-4zrz I7 "This email is intended only for the use of the individual or entity to which it is addressed and may contain inforrnation which is privileged and confidential. If the reader of this email is not the intended recipient, you are hereby notified that any disdosure, distribution, or copying of this inforrnation is strictly prohibited. If you received this email in etror, please notify the sender immediately by reply." Read: [Externa!] Unacceptable POC Coakley, Lakeshia < Lakeshia.Coakley@uhsinc.com> Wed 1111/2A171:49PM lnbox To:Sanders, Lorie D. ; lmportance: High Your message To: Subject: [External]Unacceptable POC Sent Wednesday, January 11,2017 6:49:A2 PM (UTC+00:00) Monrovia, Reykjavik was read on Wednesday, )anuasy 11,2017 6:48:58 PM (UTC+00:00) Monrovia, Reykjavik. Relayed: Unacceptable POC Microsoft Outlook Wed 1111/2a17 tl9PM to: lakeshia.coakley@uhsinc.com < lakeshia.coakley@uhsinc.com >, Delivery to these recipients or groups is complete, but no delivery notification was sent by the destination serYer: lakeshia.coakley@uhsinc.com (lakeshia.coaldev@uhsinc.com) SubjecL Unacceptable POC tha/zor/ PLAN OF CORRECTION REPORTING FORM BUREAU OF HEALTH FACILINES LICENSING \iarr". sa D.D dlrdolhth,n ls INSPECTION INFORMATION Licens6 Numbon RTF-0014 Faclllty Typs: HL- ResidentialTreatment for Children & Adolosconts Faclllty Naru: PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER lnapection Date: 1,,13t2016 Submisslon Date: o'U16t2017 Type of lnspectlon: lnvestigation ADMINISTRATOR'S CERTIFICATION By checking this box, I atteEt that I am the administralor of the facility/activity and that this plan of conec on is accurate. Additionally, I cortify that the Plan of cofl€ction describes tho action6 taken to corlsct each citsd deficiency, tho actions raken to prcvent slmilar recurEnces and the actual or expected completion date. Checked Administrator Name: Lakeshia Coakley E-maili lakeshia.coakley@uhsinc.com Phono: (803) 348-2183 RESPONSE TO CITATIONS Section: 504. B Was Completion Date Provided? Completion Date (Actuat or Expected): 0113112017 Conectlve Action: The facilities policies have been reviewed and found to be compliant with staffing ratio slandards. New procedures are in place to ensure that the staffing documentation logs clearly document a minimum of 'l staff to 5 residents during waking/program hours. During sleeping hours, th staffing documentation log s will dearly document a minimum of 1 staff to 7 residents. The logs will provide evidence that a minimum of 2 stafi shall be on each unit. At least one male and one female direct care stafr shall be present, awake and available. Staff will initial their names on the appropriate shift log. Staffing log documentation r€-training was provided by the Milieu Manager to the Team Leads on 01/13/.17. ln addition, the lower functioning unit has been divided into those who are more aggressive and those who are less aggressive. Additional unit activities have also been implemented. A new reward system has been introduced as an incentive for good behavior. lncidents are staffed daily during lhe morning rounds and during daily staff shifr brieling(s). Additional staff will be made available to assist as necessary Preventivo Action: The Milieu Manager will review staffing logs daily to ensure staff to client ralios are observed and so documented. The Executive Diroctor wil provid€ oversight Any errors found willbs shared with Leadership T€am and corrected. Staff docum€ntation re-training will be conducted as necessary lncident reduction will be discussed and addressed each week in Leadership Team. lncidents are also tracked and reported monthly for performance improvement. Program leadership will monitor incidents during daily leadership meetings and develop specific plans to address any identifled trend with either one individual youth or a collectiv€ unit. Staff ratios will be altered by leadership to respond to ths needs of the youth to ensure optimum treatment opportunilies. Optional Comments: RosponEe Approved: Yes S€qlion: Was Completion Date Provlded? Completion Date (Actual or Expoc-bd): 504.C 0't l3't 120't7 Con€ctlve Action: NiA - accepted in previous plan of correction Prsventive Actlon: Staffing log documentation re-training was provided by the Milieu Manager to the Team Leads on O'l/'13/17. The Milieu Manager will review statfing logs daily to ensure staff to cliert ratios are observed and so document€d. The Executive Director will provide oversighl. Any errors found will be shared with Leadership Team and corrected. Staff documentation re-training will be conducted as necessary Optional Comments: Response Approved: Y6s Section: Was Complelion Date Provlded? Comptetlon Date (Actuat orExpected): 902.F.'l o1131t2017 Conective Actioni N/A - accepled in previous plan of correction Pr€vontive Action: The program will ensure compliance with staff to client ratios and during all therapeutic programming, and ongoing compliance through documentation review and Leadership Rounds camera review. Any errors found will be shared in weekly Leadership meetings and documentation corrected. The Executive Director will provide oversight. Staff re-training will be provided as necessary. lncident reduction will be a method by which staff involvement and group size will be reviewed and monitored- The program will also provide additional staff training durlng monthly All Staff trainings, Dine and Dgvelopment trainings and as needed to further the therapeutic environment beginning O,l/31/,17. Program leadership will monitor incidents during daily leadership meetings and develop specific plans to address any idenlified trend with either one individual youth or a collective unit. Staff ratios will be altered by leadership to respond lo the needs of lhe youth to ensure optimu treatment opportunities. Leadership also will also provide daily on-sight review through direct observation. Optional Comment3: Respons6 Approved: Yes Section: 1002.46 Was Complotion Dat€ Provldod? Completion Date (Actual or Expected): 01t31t20't7 Con€ctivg Action: Palmetto Pee Dee will ensure that each resident will be afforded the following rights: 6.The right to be free from harm, including isolation, excessive medication, if applicable, abuse or neglect. Resident A had bite marks on more than one occasion and was bitten by another peer more than one setting (i.e. group, class). The program has divided the lower functioning unit into those who are more aggressive and those who are less aggressive. A'Special lncident Review" meeting has been developed to address high risk behaviors and incidents. The DON, Director of Risk Management, ED, Director of clinical seryices, the Patient Advocate and Director of Medical Records will prcvide input. The meeting will be held weekly and/or as needed, to better identify and address high risk behaviors/residents. Team Leads will also prompt staff during daily shifi briefings to report any high risk behaviors and/or potentiat residential conflict observed. Preventive Action: i The program will continue to ensure resident's rights in the following ways: discussion/alerts by stalf of resident behaviors during daily shift briefings (led by the Team Leads), discussions/alerts of high risk behaviors during daily Rounds meetings (if roommale changes are necessary, they will be made under the direction of the Clinical Direclor and Milieu Manager), Special lncident Review meetings held weekly o more frequently as needed, to address high risk behaviors/incidents, Some of the interventions that may result from lhe Special lncident Reviews include but are not limited to movement of a resident from one unit to another due to peer conllict, peer conflicvmediation (if appropriate), additional clinical intervention placed on youth who are aggressive including separation from other p6ers for brief individual processing and counseling, All staff have been re educated on the role of protecting all youth through supervision and immediate responding and reporting when a peer on peer assault occurs, so that appropriate nursing follow up and incident reporting can occur. ln addition, clinical therapists will provide additional direct care staff training each month during All Staff training, beginning O'l/31/17- Such training will focus on the population served, and also address conflict resolution and de-escalations lechniques. Optional Comments: Response Approved: Yes LOG INFORMATION SECTION Roport of Vlsit Delivery Date: 12D1120'16 Plan of ConBction Dus Dat6: 1116t2017 Dale Plan of Corection was Roviewed 0'1t20t2017 Reviewed by: L. Sanders, LPN Comments: Plan of Conrction Approved: Yes Decislon By: L. Sanders, LPN Dscision Dat6: 01123t2017 Remove POC: UPLOAD DOCUMENTS File Upload Plan of Conection Log Number MPCo1026-17 DHEC Fdm 0264 {05/2014) POC Accepted Sanders, Lorie D. Mon 1/23/2017 12:12PM to: lakeshia.coakley@uhsinc.com & 1 < lakeshia.coakley@uhsinc.com >; attachments (123 KB) POC letter Palmetto Pee Dee Residential.pdf; Ms. Coakley, Attached is the notification letter of the approved plan of correction for the investigation done at your facility on December 13, 2016. l,orie D.Sanders, LPN Cornplaint Department South Carolina Departrnent of Health and Environmental Control Bureau of Health Facilities Licensing Columbia Mills Office: 8og-545-424o Fax: Bo3-549-4zrz il "This email is intended only for the use of the individual or entit5r to which it is addressed and may contain inforrnation which is privileged and confidential. If the reader of t'his email is not the intended recipient, you are hereby notified that any disclosure, distribution, or copying of this inforrnation is strictly prohibited. If you received this email in er.r:or, please notifo the sender immediately by reply." hec H€ahtty Poople Healthy Communitres January 23,2017 PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER 601 GREGG AVE STE B FLORENCE, SC 29501-4316 Confidential Plan of Correction ID: MPC0I026-17 PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER : Thank you for submitting your Plan of Correction (POC) to an ivestigation report of visit dated December 13, 2016. As a result of our review, the Department accepts the facility's POC addressing the cited violations. Sincerely, Bureau of Health Facilities Licensing (803) 545-4370 Department of Health and Environrnental Conuol 260O BullStreet, Columbia, SC 29201 (8O3)898-3432 www.scdhec.gov S,C.