The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|CENTERS INC, THE||5664 SW 60TH AVE OCALA, FL||Sept. 23, 2015|
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0208|
|This STANDARD is not met as evidenced by:
Based on interview and record review, the facility failed to ensure required annual NAPPI (Non Abusive Psychological and Physical Intervention) training was completed for 4 (Staff A, B, C, and D) of 8 staff reviewed.
Record review of the personnel record for Staff A, MH/SA Tech/Transporter - Pool (MH - Mental Health Technician, SA -Substance Abuse Technician). The personnel record did not contain annual training for seclusion.
Record review of the personnel record for Staff B, MH/SA Tech/Transporter. The personnel record did not contain annual training for seclusion.
Record review of the personnel record for Staff C, LPN (Licensed Practical Nurse). The personnel record did not containing annual training for seclusion.
Record review of the personnel record for Staff D, MH/SA Tech/Transporter. The personnel record did not contain annual training for seclusion. During an interview on 09/23/2015 at 4:49 PM, Risk Manager stated we are not able to find information for four of the eight records you requested that they received their annual NAPPI training. That is the training that would include training for putting patients in seclusion. We are able to show where they received their training when they were hired but nothing about their annual training for Staff A, Staff B, Staff C, and Staff D. Staff C no longer works here. When asked if he would be required to received annual training for putting patients in seclusion, the Contract Risk Manager stated, "Yes, he should have." The training is required every year.
During an interview on 09/23/2015 at 5:19 PM, Human Resources (HR) Director, stated we changed to electronic records in the beginning of July of this year. We were not able to locate any records showing the annual updates for the employees you requested: Staff A, Staff B, Staff C, and Staff D. We have gone through the sign-in sheets and are unable to locate where these employees signed in as having received the NAPPI training. The training which includes seclusion is mandatory annually. There are NAPPI Responders and as a part of their job description. Nurses and the Mental Technicians/Substance Abuse Technicians in Building 4, this building is NAPPI Responders. They are required to have NAPPI training annually. There is no policy that says that per se, but it is required. "If these employees had the training I do not have any record of it.
Record review of the Training Matrix by Position Categories showed Required Training for Position Categories Annual showed Licensed Practical Nurses and MH/SA Tech/Transporters are required to have annual NAPPI full training. Record review of the facility's Policy and Procedure titled, "the Centers, Inc. Human Resources Policies and Procedure", date of 07/2005. Policy E: 320. Job Specific Training/Licensure/Certification. Training requirements vary from job to job and are detailed in the summary pages of your job description. Training is an important factor when determining if you are performing the essential function of your position and is mandated by various bodies governing the Centers. In order to be considered fully function in your position you must meet and maintain as current the training requirements (with or without reasonable accommodation) established for your position.
Record review of the facility's policy titled "Job Description for Job Title NAPPI Responder" updated 01/15/2015, Certificates, Licenses, Registrations - Full NAPPI, CPR (Cardiopulmonary Resuscitation) and First Aid is required.