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: DANIEL.EICHELBERGER@UHSINC.COM Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 19 Oct 2018 08:45 AM End Date: 19 Oct 2018 08:49 AM Inspector: Demetria Ceasar C o n t a c t N a m e : DANIEL EICHELBERGER C o n t a c t E m a i l : null C o n t a c t P h o n e : 843-667-0644                                                                            Overall Score 0.0%                                                                           Audit Level Notes: A complaint (M09022-18) was initiated by the Department on 10/17/18. The complaint stated the following: 1. Staff used unsafe methods/techniques during physical intervention. 2. Staff used unapproved method of behavior management. The investigation consisted of reviewing the following documentation in the office: 1. A review of the facility's Accident/Incident Reports. As a result of this investigation, the following violation of S.C. Code Ann Reg. 61-103, Standards for Residential Treatment Facilities for Children and Adolescents, was cited. Report Notice Question ID NOTICE01 Question Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 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 Answer Report Notice 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 SIGN01 Question 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. Answer 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? NO RTF Regulation Sections 500 -1300 Question ID Question 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     •   Each resident has the right to be free from harm and abuse, however on Resident A was "placed in an unsafe physical hold" and struck in the face by Staff Member A. On Resident B was pushed against a wall and placed in a headlock by Staff Member Answer OUT B. Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention 11/30/2018 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: 10/19/2018 Submission Date: 10/26/2018 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: Dan Eichelberger E-mail: daniel.eichelberger@uhsinc.com Phone: (843) 667-0644 RESPONSE TO CITATIONS Section: Was Completion Date Provided? Completion Date (Actual or Expected): 1002.A.6 Yes 10/26/2018 Corrective Action: Both staff noted in the citation were immediately suspended as the facility conducted the investigation. The facility reported the incidents to DHEC and SCDSS-OHAN. Both staff were ultimately terminated. Preventive Action: The facility has implemented a refresher training for staff that focuses on verbal de-escalation and use of physical interventions. Additionally, a restraint reduction committee has been created to collect data, identify trends, and assist in providing information in order to train staff on how and when to implement physical interventions. Optional Comments: Response Approved: Yes http://intraprod/PlanOfCorrection/FormSessionRenderReadOnlyPOC.aspx?formSessionId=45524 1/2 11/30/2018 ReadOnlyPOC LOG INFORMATION SECTION Report of Visit Delivery Date: Plan of Correction Due Date: Date Plan of Correction was Reviewed: 10/26/2018 Reviewed by: AS Comments: Plan of Correction Approved: Yes Decision By: AS Decision Date: 10/26/2018 Remove POC: UPLOAD DOCUMENTS File Upload Plan of Correction Log Number: MPC10057-18 DHEC Form 0284 (05/2014) http://intraprod/PlanOfCorrection/FormSessionRenderReadOnlyPOC.aspx?formSessionId=45524 2/2