CMS HSC Inspection

DEPARTMENT OF SOCIAL SERVICES
HUMAN SERVICES CENTER

POBOX7600
YANKTON, SD 57078-7600
PHONE: 605-668-3100
FAX: 605-668-3460
WEB: dss.sd.gov
April 13, 2016
CMS - Certification & Enforcement Branch

Attn: Helen Jewell
1961 Stout Street, Room 08-148
Denver, CO 80294
RE: Conditions for Participation (CoPs)- SD Human Services Center
Dear Ms. Jewell:

Enclosed is the Addendum Plan of Correction for the South Dakota Human Services Center. This is in
regards to the recertification survey conducted at our facility on March 2, 2016 by CMS.
Should you have any questions regarding the plan of correction, please contact Glenn Black,
Administrator at 605-668-3102.
Sincerely,
Gif:J.Mtv
Administrator
GJB:ss
Enclosures
APR 14'i611=1iAM
Physical Delivery Address - 3515 Broadway Avenue, Yankton, South Dakota 57078
Printed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING _ _ _ _ _ _ __
(X1) PROVIDER/SUPPLIER/CUA
IDENTIFICATION NUMBER:
03/02/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
SOUTH DAKOTA HUMAN SERVICES CENTER
(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
NAME OF PROVIDER OR SUPPLIER
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078
SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
B 000 INITIAL COMMENTS

An unannounced Recertification survey was
conducted by Federal consulting surveyors from
February 29, 2016 to March 2, 2016. The census
at the time of this survey was 91 patients; the
sample was eight (8).
B 098 482.60 SPEC PROVISIONS APPLYING TO
PSYCH HOSPITALS
The hospital must meet all special provisions
applying to psychiatric hospitals.
This Condition is not met as evidenced by:

Based on interview and document review, the
facility failed to ensure that patients who were
housed and treated in designated units/beds for
acute psychiatric care were receiving services for
the diagnosis and treatment of mentally ill
persons. Due to low patient census the facility
moved the adolescent patients receiving chemical
dependency rehabilitation services in a
Non-Distinct Part (non-certified) unit to the
Distinct Part (certified) Unit and integrated them
with the adolescent patients who receive services
for the diagnosis and treatment of mental illness.
This practice results in improper use of
areas/services certified for the delivery of acute
psychiatric care and impacts the quality treatment
of patients receiving psychiatric services. (Refer
to 899)
B 099 482.60(a) SPEC PROVISIONS APPLYING TO
PSYCH HOSPITALS
Psychiatric hospitals must be primarily engaged
in providing, by or under the supervision of a
doctor of medicine or osteopathy, psychiatric
services for the diagnosis and treatment of
mentally ill persons.
ID
PREFIX
TAG
8000
POST OFFICE BOX 7600

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
he plan of correction completion and monitoring

ill be reported to the HSC governing body. The
dministrator of the facility has overall
responsibility for development and
implementation of the Poe.
dolescent patients receiving chemical

ependency treatment will be transitioned from
8098 he certified unit to other community inpatient
ettings or discharged with completion of
reatment. New admissions to the chemical
ependency program were discontinued.
Each patient residing on the certified unit who
re receiving chemical dependency treatment
ill be assessed by the treatment team.
Referrals and discharge plans to the appropriate
evel of care will be made and carried out.
he policy and procedure Patient Unit
Relocation will be reviewed and revised. This
policy will include a review by the Administrator,
Medical Director, Directors of Operations,
linical Services, and Nursing, prior to any unit
mbinations to ensure proper licensure for
patients served. All temporary unit closures or
ombinations will be reported to the Director of
Health Information and Quality Management.
he Director of Health Information and Quality
Management will review the Patient Unit Closure
hecklist to ensure that patients who are housed
nd treated in designated units/beds for acute
psychiatric care are receiving services for the
iagnosis and treatment of mentally ill persons.
he Director of Health Information and Quality
B 099 Management will report the findings of these
reviews to the Quality Council until the Quality
/22/16
ouncil indicates standards are met and
reporting is no longer necessary.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(XS) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused fr
correcting proliding it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
UX5311
If continuation sheet Page 1 of 43
Printed:
OMB NO 0938-0391
(X1) PROVIDER/SUPPLIER/CLIA
A. BUILDING _ _ _ _ _ _ __
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

B 000 INITIAL COMMENTS
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 000 8098 (continued from page 1)
~ddendum:
An unannounced Recertification survey was
conducted by Federal consulting surveyors from
February 29, 2016 to March 2, 2016. The census
at the time of this survey was 91 patients; the
sample was eight (8).
B 098 482.60 SPEC PROVISIONS APPLYING TO
PSYCH HOSPITALS
irhe Director of Health Information and Quality

Management will report to Quality Council
Monthly, the results of the reviews of Patient Uni1
Closure Checklist. The expectation is 100%
compliance with no combining of units with
different licensure. Upon 6 months of 100%
B 098 compliance, the Quality Council may indicate
~,,,');(,
~tandards are met and reporting is no longer
. *1V4
11
need to be required.
The hospital must meet all special provisions

applying to psychiatric hospitals.

to 899)
B 099 482.60(a) SPEC PROVISIONS APPLYING TO
PSYCH HOSPITALS
8099
Psychiatric hospitals must be primarily engaged

in providing, by or under the supervision of a
doctor of medicine or osteopathy, psychiatric
services for the diagnosis and treatment of
mentally ill persons.
TITLE
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
UX5311
IA
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 099
3515 BROADWAY AVE

YANKTON, SD 57078

Continued From page 1
This Standard is not met as evidenced by:

of patients receiving psychiatric services.
Findings include:
A. On 2/29/16 at 9:45 a.m. the Director of Quality
Management reported that adolescent patients
receiving treatment for chemical dependency
(CD) had been moved from a Non-Distinct Part
Unit (P2) to the adolescent Distinct Part Unit (02)
due to a low census on both Units. This change
was implemented on June 18, 2015.
B. During observation of the 02 Unit and
interview with 02 staff members, Program
Director 1 and Chemical Dependency Supervisor
2 reported that CD adolescent patients were
assigned rooms on the unit halls with the
adolescent patients receiving services for
psychiatric care, but not as roommates. They
reported that the CD patients receive
programming treatment separate from the
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8099 8099
Adolescent patients receiving chemical
dependency treatment will be transitioned from
he certified unit to other community inpatient
settings or discharged with completion of
dependency program were discontinued.
Each patient residing on the certified unit
eceiving chemical dependency treatment will be
assessed by the treatment team. Referrals and
discharge plans to the appropriate level of care
will be made and carried out.
[The policy and procedure Patient Unit
Clinical Services, and Nursing, prior to any unit
~mbinations to ensure proper licensure for
combinations will be reported to the Director of
[The Director of Health Information and Quality
Checklist to ensure that patients who are housed
and treated in designated units/beds for acute
psychiatric care are receiving services for the
~iagnosis and treatment of mentally ill persons.
Management will report the findings of these
~ouncil indicates standards are met and
~ddendum:
4/22/16
~ompliance with no combining of units with
~ifferent licensure. Upon 6 months of 100%
~ompliance, the Quality Council may indicate
$tandards are met and reporting is no longer
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 099
3515 BROADWAY AVE

YANKTON, SD 57078


patients receiving psychiatric services, but added
that the patients were combined for
activities/groups offered on evenings, weekends
and holidays. They reported that the CD patients
are hospitalized on the 02 unit for 30-90 days.
C. Review of patient census for the first day of the
survey (2/29/16) revealed that there were CD
patients (H1, HS, H7, HB, H9 and H13) housed on
02 Unit with six (6) patients receiving psychiatric
services including active sample Patient H3.
D. Review of documents provided by the Director
of Quality Management revealed that an
additional 19 adolescent patients had received
care and treatment for Chemical Dependency
since June 18, 2015.
E. During interview on 2/29/16 at 3:20 p.m., RN4

reported that nursing staff are responsible for the
CD adolescent patients except for CD focused
formal programming (groups/activities).
B 103 482.61 SPEC MEDICAL RECORD REOS FOR
PSYCH HOSPITALS
The medical records maintained by a psychiatric
hospital must permit determination of the degree
and intensity of the treatment provided to
individuals who are furnished services in the
institution.

Based on observation, interview, and record
review, the facility failed to:
1. Ensure that patients who were housed and
treated in designated units/beds for acute
psychiatric care were receiving services for the
diagnosis and treatment of mentally ill persons.
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 099 8103 (1.)

~dolescent patients receiving chemical
k:lependency treatment will be transitioned from
the certified unit to other community inpatient
treatment. New admissions to the chemical
k:lependency program were discontinued.
receiving chemical dependency treatment will be
k:lischarge plans to the appropriate level of care
!fhe policy and procedure Patient Unit
combinations to ensure proper licensure for
rhe Director of Director of Health Information
and Quality Management will review the Patient
B 103 Unit Closure Checklist to ensure that patients
who are housed and treated in designated
units/beds for acute psychiatric care are
eceiving services for the diagnosis and
reatment of mentally ill persons. The Director of
Health Information and Quality Management will
report the findings of these reviews to the Quality
Council until the Quality Council indicates
standards are met and reporting is no longer
necessary.
Addendum:
The Director of Health Information and Quality
different licensure. Upon 6 months of 100%
compliance, the Quality Council may indicate
4/22/16
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
3515 BROADWAY AVE

YANKTON, SD 57078

8 103 Continued From page 3

Due to low patient census the facility moved the
adolescent patients receiving chemical
to 899)
II. Provide active individualized psychiatric
treatment, including alternative treatment
interventions for one (1) of eight (8) active sample
patients (87), who was not motivated to attend
groups listed on the unit schedule. This patient
spent many hours without structured activities
spending most of his/her time in his/her bedroom
or sitting in the day room. Failure to provide
active treatment can result in longer
hospitalization and delayed recovery. (Refer to
81251)
Ill. Ensure that patients in one (1) of eight (8)
units (C2) were offered treatment modalities on a
regularly scheduled basis. There were no
structured groups/activities offered on a regular
basis for patients housed on the adult wing of
Unit C2, including active sample Patient F5.
Failure to provide sufficient hours of active
treatment prevents patients from achieving their
optimal level offunctioning, thereby potentially
delaying a timely discharge. (Refer to 812511)
IV. Appropriately use and document
seclusion/restraint as external controls of violence
toward self and others for four (4) of eight (8)
active sample patients (87, 810, F1 and H3) and
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8 103 8103 (11.)

Self-paced worksheets and workbooks with
individual staff review with patient will be
provided as alternative treatment options. All
patient treatment plans will be reviewed and
revised to include options for active treatment
based on the patient's assessed strengths,
needs, and interests as needed.
The policy "Treatment Plan" will be reviewed
and revised to provide for the provision of
alternative treatment. Treatment plans of current
patients will be reviewed by the unit Charge
Nurses to ensure inclusion interventions for
providing alternative forms of active treatment as
needed.
Education on the options available for active
reatment and the policy change will be provided
o all staff. Treatment plans of current patients
will be reviewed by the unit Charge Nurses to
~nsure inclusion interventions for providing
!alternative forms of active treatment.
A unit treatment log will be created to monitor
~reatment participation and the provision of
!alternative treatment options for patients who
refuse groups or are unable to participate.
~reatment, the unit activity log, and the policy
~hange will be provided to all staff.
The Program Directors (2) will review unit
!activity logs weekly to ensure the provision of
!alternative treatment options to patients. The
Program Directors will report the results of the
reviews to the Director of Clinical Services for
review and corrective action to ensure
compliance. The Director of Clinical Services will
report the findings to the Quality Council until the
KJuality Council indicates standards are met and
~ddendum:
rT"he Director of Clinical Services will report
results of active treatment audits to the Quality
Council monthly. The expectation is 90%
compliance. Upon 6 months of 100%
~tandards are met and reporting to Quality
~ouncil is no longer required.
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 103
3515 BROADWAY AVE

YANKTON, SD 57078

Continued From page4

three (3) of three (3) discharged patients (X 1, X2
and X3) reviewed for the use of these
procedures. In addition, the facility failed to
ensure privacy for discharged Patient X3 who
was taken out into the areas (hallways and
dayroom) while s/he was in ambulatory
restraints. These patients were
secluded/restrained without documented
justification based on changing behaviors and
there was failure to use proper release criteria for
seclusion. Patients were secluded alone and with
others on wards. One (1) of three (3) discharged
patients (X3) was in ambulatory restraints
continuously for almost 6 days. Safety (spitting)
hoods, rather than defensive gear for staff, were
used on patients, sometimes without proper
justification. Transport boards were used
inappropriately as restraint beds. These
deficiencies resulted in safety risks, violations of
the patients' right to be free from undue restraint
and failure to ensure privacy for patients. (Refer
to 8125 Ill)
B 116 482.61(b)(6) PSYCHIATRIC EVALUATION

Each patient must receive a psychiatric
evaluation that must estimate intellectual
functioning, memory functioning and orientation.

Based on record review and interview, there was
failure to provide psychiatric evaluations that
reported orientation, memory functioning and/or
intellectual functioning in measurable, behavioral
terms for six (6) of eight (8) sample patients (81,
87, 05, F1, F5 and H3). This compromises the
database from which diagnoses are determined
and from which changes in response to treatment
interventions may be measured.
03/02/2016
STREET ADDRESS. CITY. STATE, ZIP CODE
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 103 8103 (Ill)

A schedule for active treatment groups was
created and implemented on Cedar 2 on
4/13/16. Self-paced treatment options will also
be implemented on Cedar 2 for patients that
were unable or did not wish to participate in
group activities.
A unit treatment log will be created and
implemented on Cedar 2 to track patient
involvement in group or individual treatment.
Staff education on activity schedule, activity log,
~nd self-paced treatment work will be provided
!for all Cedar 2 staff.
Program Directors (2) will review unit activity log
weekly to ensure the providing of active
lreatment. Findings of these reviews will be
provided to the Director of Clinical Services for
review and corrective action. The Director of
Clinical Services will report the findings to the
Quality Council until the Quality Council
indicates standards are met and reporting is no
onger necessary.
B 116 i'\ddendum:
The Director of Clinical Services will report
standards are exceeded and reporting to Quality
Council is no longer required.
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING
B 103
3515 BROADWAY AVE

YANKTON, SD 57078


three (3) of three (3) discharged patients (X1, X2
to 8125 Ill)


COMPLETED
03/02/2016
(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

(XS)
COMPLETION

DEFICIENCY)
DATE
B 103 8103 IV.

The policies related to physical restraints will be
eviewed and revised to ensure patient privacy
When physical or mechanical restraints are used.
irhe use of the safety frame (transport board) will
be discontinued. The safety frame will be
removed from policy. Safety hoods will be
removed from policy and use will be
c1iscontinued. The presence of a staff member
on the unit at all times when Cedar 2 is occupied
was required effective 3/2/16. The policies
related to physical restraints will be revised to
add the RN reviewing documentation, assessing
patient for earliest release from restraint or
seclusion and documenting assessment at least
hourly in the medical record. The Physical
Restraint/ Chemical Restraint/ Seclusion
Monitoring Progress Note was revised to include
a nursing assessment of patient behavior at
least hourly.
Safety Chairs will be ordered to replace the
Safety frames. All staff will be provided
education on the use of the Safety Chair and
policy change. Defensive protective equipment
(face shields and bite protection sleeves) will be
ordered. All staff will be provided education on
B 116 he use of the protective equipment and policy
change. All staff will be provided re-education on
he requirement for earliest possible release
'ram restraint or seclusion by the Human Rights
Specialist.
The Human Rights Specialist and the Director
of Health Information and Quality Management
Will review each episode of the use of restraint or
seclusion to ensure compliance. Any concerns
Will be reported to the Medical Director and
~dministrator for corrective action. Daily staffing
sheets for Cedar 2 will be reviewed weekly by
he Nurse Managers (2) to ensure staff presence
on the unit when occupied. Findings of these
reviews will be reported to the Director of
Nursing or designee weekly for review and
corrective action. Each of the responsible parties
above will report findings to the Quality Council
until the Quality Council indicates standards are
met and reporting is no longer necessary.
UX5311
56
Printed:
OMB NO 0938-0391
A. BUILDING
B 103
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


to 8125111)

ID
PREFIX
TAG
B 103

DEFICIENCY)
(XS)
COMPLETION
DATE
B103 (IV) continued

DON or Designee will report results of staffing
audits to Quality Council monthly. Expectation is
90% compliance, with C2 staffed when patients
are on the unit. Upon 6 months of 100%
needed. Director of Health Information and
Quality Management will report audits of
Seclusion and Restraint Events to ensure
elease at earliest time. Expectation is 100%
compliance, Quality Council May indicate
standards are met and reporting to Quality
Council is no longer required. Addendum:
4/22/16
The Director of HI/QM will report findings of
audits of Psychiatric Evaluations for inclusion of
Orientation, memory functioning and/or
intellectual functioning in measurable terms to
he Quality Council. The expectation is 100%
compliance. Upon 6 months of 100 %
!Council is no longer required.
Addendum
B 116 The Director of Health Information and Quality
Management will report audits of Seclusion and
Restraint Events and DON or designee will
report audits of staffing sheets to the Quality
Council monthly.

UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 103
3515 BROADWAY AVE

YANKTON, SD 57078


to 8125 Ill)


87, D5, F1, F5 and H3). This compromises the
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 103
8116
A template for completion of psychiatric
~valuations was created to include orientation,
B 116 memory functioning and/or intellectual
,unctioning in measurable, behavioral terms.
The policy "Psychiatric Evaluation" was
reviewed to ensure inclusion of orientation,
memory functioning and/or intellectual
Wunctioning in measurable, behavioral terms.
Education will be provided to all Psychiatry
~taff on the standards for psychiatric evaluation
~nd the template for completion.
Education will be provided to all Psychiatry staff
~n the standards for psychiatric evaluation and
~he template for completion.
Director of Health Information and Quality
Management will review 10% of all psychiatric
evaluations each month for inclusion of
~rientation, memory functioning and/or
jntellectual functioning in measurable, behavioral
~erms. The Director of HI/QM will report findings
weekly to the Medical Director. The Medical
Director will meet monthly with Psychiatric Staff
UX5311
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OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 103
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


to 8125111)
ID
PREFIX
TAG

CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY)
(XS)
COMPLETION
DATE
B 103 8116 continued

~o review and continue to educate to ensure
compliance. Psychiatric staff performance out of
~mpliance will be referred to Medical Executive
~mmittee and President of Medical Staff for
corrective actions.
Addendum:
Jhe Director of HI/QM will report findings of
"ntellectual functioning in measurable terms to
he Quality Council. The expectation is 100%
compliance. Upon 6 months of 100 %
4/22/16
Addendum:
he Quality Council monthly.
B 116


terms for six (6) of eight (8) sample patients (B 1,
UX5311
5e...
Printed:

OM8 NO 0938-0391
A. BUILDING
(X4)1D
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8 116
Findings include:
A. Document Review
1. Patient 81: The psychiatric evaluation
(2/17/16) failed to address memory or intellectual
functioning.
2. Patient 87: The psychiatric evaluation (2/5/16)
failed to address to address orientation, memory
or intellectual functioning.
3. Patient 05: The psychiatric evaluation
(1/22/16) failed to address orientation, memory or
intellectual functioning.
4. Patient F1: The psychiatric evaluation (1/6/16)
stated, "Patient does not respond to formal
mental status exam." The follow-up progress
note (1nt16) documented orientation, but failed
to address memory or intellectual functioning.
5. Patient F5: The psychiatric evaluation (2/11/16)
failed to address orientation, memory or
intellectual functioning.
6. Patient H3: The psychiatric evaluation
(9/20/15) failed to give basis for memory
assessment. The statement read: "Memory is
fairly reliable for history."
8. Interview:
During interview on 3/2/16 at 10:30 a.m., the
Medical Director acknowledged the above patient
findings. Regarding Patient F5, he reported that
it was especially important that the basis for this
information be documented as this patient is
receiving ECT.
8 117 482.61(b)(7) PSYCHIATRIC EVALUATION
8 117
UX5311
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OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

B 118 Continued From page 7

Each patient must have an individual
comprehensive treatment plan.

Based on medical record review and interview,
treatment plans were developed by a Counselor
(Social Service paraprofessional), rather than by
the treatment team. This inappropriate delegation
of responsibility for patient treatment planning to
non-professional unlicensed team members
resulted in treatment plans that were not
individualized based on individual patient needs.
Findings include:
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8118 8118
!The treatment plan format was revised to reflect
the creation of the treatment plan by licensed
members of the treatment team.
!The policy ''Treatment Plan" will be reviewed and
revised to define the treatment team members
responsible for the creation of the treatment plan
~s professional staff in the disciplines of
Psychiatry, Nursing, Social Work, Occupational
rJ"herapy, Physical Therapy, Dietetics, and
Speech Therapy. The Class Specification for the
position Human Services Counselor will be
reviewed and revised. The development of
patient treatment plan will be removed from the
iob function.
Education on the new treatment plan format and
l:>olicy revision will be provided to all staff.
A. Record Review:
A. Review of treatment plans for eight (8) of eight

(8) active sample patients (dates of plans in
parentheses): 87 (2/4/2016); 810 (2/16/16); 05
(1/28/16); E10 (dated 12/24/15); F1 (2/29/16); F5
(2/10/16); G2 (dated 12/29/16) and H3 (10/6/15
with unclear review date) revealed that the
majority of interventions were assigned to a
counselor (unlicensed social work
paraprofessional); these interventions included
both 1: 1 and group therapies. The treatment plan
for one (1) of eight (8) sample patients (F1)
assigned the responsibility for the implementation
and evaluation of all interventions to the
counselor, including nursing safety interventions.
All interventions for one (1) of eight (8) sample
patients (F5) were assigned to a counselor or an
activity therapist.
B. Interview
rrhe Nurse Managers (2) will review 10% of all

patient treatment plans to ensure the treatment
plans were created and developed by
professional members of the treatment team as
defined in policy. Nurse Managers will report the
findings of these reviews to the Director of
corrective actions. The DON or designee will
report the results of these findings to the Quality
necessary.
Addendum:
lfhe DON or designee will report the results of
~he treatment plan audits to the Quality Council
monthly. The expectation is 100% compliance
With treatment plans created and developed by 4/22/16
professional members. Upon six months of
100%, the Quality Council may indicate
$tandards are met and reporting to Quality
1. During interview on 3/1/16 at 11 :00 a.m. and

review of active Patient D5's treatment plan,
UX5311
Printed:
03/23/2016
FORM APPROVED

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B. WING _ _ _ _ _ _ _ _ __
434003
(X4)1D
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
3515 BROADWAY AVE

YANKTON, SD 57078


Counselor 7 reported that he developed the
treatment plans and submitted these "treatment
plans during patient rounds." When discussing
repetition of the RN interventions, Counselor 7
stated, ''You'll find the same ones."
ID
PREFIX
TAG

DEFICIENCY)
(XS}
COMPLETION
DATE
B 118
2. During interview with review of treatment plans

on 3/2/16 at 11 :00 a.m., the Director of Clinical
Services and the Director of Social Work
acknowledged that some of the treatment
interventions that should have been assigned to
professional staff were assigned to the
counselors (unlicensed paraprofessionals).
C. Review of the Class Specification (9/06) for the
Human Services Counselor revealed the
following statements:
1. "The Human Services Counselor develops
treatment plans and conducts individual and
group counseling sessions for patients who have
mental health needs."
2. "Reviews case histories, biographies, and
other data pertaining to patients in order to
determine problems, their causes and possible
remedies."
3. "Develops and implements appropriate
therapeutic treatment modalities for patients
across the lifespan."
B 122 482.61(c)(1)(iii) TREATMENT PLAN
B 122
The written plan must include the specific

treatment modalities utilized.

Based on record review and interview, the facility
failed to develop treatment plans that clearly
UX5311
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03/23/2016
FORM APPROVED

OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
8122
03/02/2016

(X4)1D
PREFIX
TAG
COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
(X3) DATE SURVEY
3515 BROADWAY AVE

YANKTON, SD 57078


delineated physician, nursing and social work
interventions to address the specific treatment
needs of eight (8) of eight (8) active sample
patients (dates of plans in parentheses): 87
(2/4/2016); 810 (2/16/16); 05 (1/28/16); E10
(dated 12/24/15); F1 (2/29/16); F5 (2/10/16); G2
(dated 12/29/16) and H3 ( 10/6/15 with unclear
review date). Instead most of the interventions
for these professionals were routine, generic
discipline functions that lacked focus for
treatment. This resulted in treatment plans that
failed to reflect a comprehensive, integrated,
individualized approach to multidisciplinary
treatment.
Findings include:
A. Treatment Plan Review:
1. Patient 87
For the problem "Hallucinations" Patient 87, MTP
there was no listed interventions for physicians or
nursing.
2. Patient 810
For the problem "Psychosis" Patient 810 MTP
interventions stated:
a. "Psychiatrist will prescribe and monitor
medications for illness" frequency and duration of
this generic intervention was not included.
b. "RN will provide medication education" the
frequency and duration of the intervention was
not included.
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8122 8122
The treatment plan format for all patient
.reatment plans will be changed to clearly
indicate the involvement of professional staff.
The new format allows for individualization
specific to patient needs and strengths.
Education will be provided to all professional
staff on treatment planning, the individualization
of treatment plans, and the roles of professional
staff in the treatment planning process.
The Nurse Managers (2) will review 10% of all
patient treatment plans to ensure proper
delineation of interventions for professional staff.
Nurse Managers will report the findings of these
eviews to the Director of Nursing or designee
weekly for review and corrective actions. The
DON or designee will report the results of these
'indings to the Quality Council until the Quality
Council indicates standards are met and
4/22/16
Addendum:
The DON or designee will report the results of
reatment plan audits to the Quality Council
with treatment plans defined proper delineation
of interventions for professional staff. Upon six
months of 100%, the Quality Council may
"ndicate standards are met and reporting to
Quality Council is no longer required.
3. Patient 05
a. For problem, "recent self-harm attempts," there
were no nursing interventions to guide staff in the
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OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 122
care of this patient in the clinical area.

b. For problem, "assaulting staff and destroying
property at [his/her] last placement," there were
no nursing interventions to guide staff in the care
of this patient in the clinical area when patient
was showing assaultive behavior. The only
nursing interventions were role functions listed as
"Nurse will provide education re: benefits, side
effects and risks" and "Nurse will administer
medications and monitor for effectiveness and
side effects." The same nursing intervention,
"Nurse will administer medications and monitor
for effectiveness and side effects" was again
listed for another goal under the same problem.
Another generic nursing intervention listed for this
problem was, "Nurse will provide pharmacy
pamphlets and education on prescribed
medication and diagnosis."
c. For problem, "discharge/aftercare plan,"
generic social work interventions were listed as
"SW (Social Work) will keep informed of patient's
treatment progress and needs by weekly
attendance at treatment team meetings." "SW
will meet with patient at least monthly to discuss
patient's progress and needs." "SW will maintain
at least monthly contact with parents/guardian
regarding Patient's progress and needs." "SW
will contact appropriate mental health and
educational resources prior to discharge and
assist in scheduling aftercare appointments."
d. Even though this patient participated in
groups/activities, these modalities were not
clearly identified and correlated to the stated
goals in [his/her] treatment plan. Instead, Youth
counselor (social work paraprofessional)
interventions were listed as "Staff will offer pt.
UX5311
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OMB NO 0938-0391
A. BUILDING
(X4)1D
B 122
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
{XS)
COMPLETION
DATE
B 122
(patient) the chance for 1 :1 and group therapy to

talk about situations [s/he] had used (sic)
unhealthy coping skills." "Patient will be offered
the opportunity for 1:1 therapy to discuss coping
skills identified."
4. Patient E10
For the problem "Paranoia" Patient E10, MTP
there was no listed interventions for physicians or
nursing.
5. Patient F1
a. For problem identified as "Recent increase in
motor activity: hitting doors, windows and walls,
jumping on furniture and throwing chairs," there
were no physician or nursing interventions.
b. All interventions for this problem were assigned
to a counselor (social work paraprofessional),
including the safety interventions.
c. Even though Patient F1 presently very
unorganized, irritable behavior -running around
day room and jumping on furniture--during
observations on 2/29/16 at 4:00 p.m. and on
3/1/16 at 9:15 a.m., there were counselor
interventions listed that were inappropriate for the
patient at this time. There were "Treatment
materials on A. Coping Skills, B. Anxiety and C.
Anger Management" and "Offer unit programming
groups and activities as indicated on unit
schedule."
6. Patient F5
a. For problem identified as "medication
management: Pt (Patient) is off [his/her]
prescribed medications and is very irritable,"
UX5311
Printed:
OMB NO 0938-0391
{X2) MULTIPLE CONSTRUCTION
A. BUILDING _ _ _ _ _ _ __
{X1) PROVIDER/SUPPLIER/CUA
B 122
03/02/2016

{X4)1D
PREFIX
TAG
{X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

{EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

Youth counselor (social work paraprofessional)
generic interventions were listed as "Maintain
current level offunctioning." "Encourage patient
to get involved in activities."
ID
PREFIX
TAG

{EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATE
B 122
b. Even though this patient was receiving ECT

{Electric Convulsive Therapy), there were no
physician and nursing interventions listed. In
addition, there were no nursing interventions to
address this patient's irritability in the clinical area.
7. Patient G2
For the problem "Patient has a need for positive
coping skills, as evidence by recent attempts of
suicide". Patient G2, MTP interventions stated:
a. "Psychiatrist will prescribe Ability and monitor
patient for treatment of patient's depression."
Frequency and duration not included.
b. "Nurse will administer medication and monitor
for effectiveness and side effects."
c. "Nurse will provide feedback re: patient's
timeliness and compliance of taking prescribed
medications."
8. Patient H3
a. For problem, "assaultive behavior and anger
outbursts," there were no nursing interventions to
guide staff in the care of this patient in the clinical
area when patient was showing assaultive
behavior.
b. For problem, "ADHD evidenced by patient's
impulsive behavior," the only nursing
interventions were generic. These were: "Nurse
will provide education re: benefits, side effects
and risks" and "Nurse will administer medication
and monitor for effectiveness and side effects."
"Nurse will provide pharmacy pamphlets and
education on prescribed medication and
UX5311
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OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 122
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


diagnosis."
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 122
The intervention, "Nurse will provide education re:

benefits, side effects and risks" was listed for
another goal for this same problem.
c. For problem, "self-harm behavior," there were
no specific nursing interventions to guide staff in
the care of this patient in the clinical area. The
only nursing interventions identified were generic.
These were: "Nurse will provide education re:
benefits, side effects and risks" and "Nurse will
administer medication and monitor for
effectiveness and side effects." "Nurse will
provide pharmacy pamphlets and education on
prescribed medication and diagnosis."
The intervention, "Nurse will provide education re:
benefits, side effects and risks" was listed for
another goal for this same problem.
d. For problem, "discharge/aftercare plan,"
generic social work interventions were listed as
"SW (Social Work) will keep informed of patient's
treatment progress and needs by weekly
attendance at treatment team meetings." "SW
will meet with patient as needed to discuss
patient's progress towards transfer or discharge."
"SW will maintain contact with guardian(s)
regarding patient's progress and needs." "SW
will contact appropriate resources prior to
discharge and assist in scheduling aftercare
appointments or placement."
B. Interview:
1. During interview on 3/1/16 at 11 :00 a.m. and

review of active Patient D5's treatment plan, RN5
acknowledged that the nursing interventions were
not individualized and were repeated in the plan.
UX5311
Printed:
03/23/2016
FORM APPROVED

OMB NO 0938-0391
A. BUILDING
B. WING _ _ _ _ _ _ _ _ __
434003
B 122
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 122
2. In an interview on 3/1/16 at 1:45 P.M. with the

Nurse Supervisor one (1) for the Adolescent units
and Nurse Supervisor two (2) for the Acute
Admission Units, the generic nursing
interventions that do not include frequency and
duration and the lack of nursing intervention on
some MTPs were discussed. They both agreed
intervention listed on some of the MTPs were
regular RN responsibilities. Nurse Supervisor 1
stated "I see what you are saying." They also
agreed that some of the MTP did not have
nursing interventions listed.
acknowledged that the social work interventions
were not individualized. The Director of Social
Work stated, "The interventions should be
selected by each profession."
B 123 482.61(c)(1)(iv)TREATMENTPLAN
The written plan must include the responsibilities
of each member of the treatment team.

Based on medical record review and interview,
the responsibility for the implementation and
evaluation for the majority of treatment plan
interventions were assigned to a Counselor
(Social Service paraprofessional), rather than to a
professional treatment team member. This
deficiency resulted in an inappropriate delegation
of responsibility for patient treatment to
non-professional unlicensed team members and
confusion in the responsibilities of the team.
B 123 8123
reatment plans will be revised to include a
signature line on the Master Treatment Plan
(MTP) and an initial box with responsible
discipline with each intervention. All patients will
receive an Initial Treatment plan upon admission
which includes a signature from the responsible
professional discipline.
The policy "Treatment Plan" will be reviewed and
revised to ensure the appropriate level of
responsibility for the identified problems, goals
and interventions was assigned to the
appropriate professional staff member of the
reatment team.
Education on treatment planning process, the
policy change, and the roles of each treatment
earn member will be provided to all staff.
Findings include:
UX5311
Printed:
OM8 NO 0938-0391
(X1) PROVIDERISUPPLIER/CLIA
A. BUILDING _ _ _ _ _ _ __
8 123
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


A. Record Review:
A. Review of treatment plans for eight (8) of eight
(8) active sample patients (dates of plans in
parentheses): 87 (2/4/2016); 810 (2/16/16); 05
(1/28/16); E10 (dated 12/24/15); F1 (2/29/16); F5
(2/10/16); G2 (dated 12129/16) and H3 (10/6/15
with unclear review date) revealed that the
majority of interventions were assigned to a
counselor (unlicensed social work
paraprofessional); these interventions included
both 1:1 and group therapies. All interventions in
the treatment plan for one (1) of eight (8) sample
patients (F1), including nursing interventions for
safety, were assigned to the counselor.
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8 123 8123 continued

rrhe Nurse Managers (2) will review 10% of all
patient treatment plans to ensure the
responsibilities of each member of the treatment
~earn are evident and appropriate for the level of
licensure. Nurse Managers will report the
findings of these reviews to the Director of
corrective actions. The DON or designee will
report the results of these findings to the Quality
necessary.
4/22/16
l\ddendum:
reatment team audits to the Quality Council
with treatment team members have appropriate
evels of responsibility with appropriate licensure.
Upon six months of 100%, the Quality Council
may indicate standards are met and reporting to
8. Interview
on 3/1/16 at 12:15 p.m., Nurse Supervisor one (1)
and Nurse Supervisor two (2) acknowledged that
the majoring of nursing interventions were role
functions, rather than individualized based on
patient needs.
2. During a conference with facility staff on 3116
at 1:30 p.m., the Director of Social Work
acknowledged that most groups/activities are
delegated to non-licensed social work
paraprofessionals (counselors).
acknowledged that some of the treatment
interventions that should have been assigned to
professional staff were assigned to the
counselors (unlicensed paraprofessionals).
8 125 482.61(c)(2) TREATMENT PLAN
8125
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OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
PREFIX
TAG
03/02/2016
3515 BROADWAY AVE

YANKTON, SD 57078


The treatment received by the patient must be
documented in such a way to assure that all
active therapeutic efforts are included.

Based on observation, interview and document
review, the facility failed to ensure that patients
who were housed and treated in designated
units/beds for acute psychiatric care were
receiving services for the diagnosis and treatment
of mentally ill persons. Due to low patient census
the facility moved the adolescent patients
receiving chemical dependency rehabilitation
services in a Non-Distinct Part (non-certified) unit
to the Distinct Part (certified) Unit integrated them
to 899)
In addition, the facility failed to:
I. Provide active individualized psychiatric
hospitalization and delayed recovery.
II. Ensure that patients in one (1) of eight (8) units
(C2) were offered treatment modalities on a
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 125 8125
dependency program were discontinued.
receiving chemical dependency treatment will be
discharge plans to the appropriate level of care
!The policy and procedure Patient Unit
pombinations to ensure proper licensure for
IThe Director of Health Information and Quality
~hecklist to ensure that patients who were
acute psychiatric care are receiving services for
~he diagnosis and treatment of mentally ill
persons. The Director of Health Information and
Quality Management will report the findings of
~hese reviews to the Quality Council until the
Quality Council indicates standards are met and
~ddendum:
rhe Director of Health Information and Quality
UX5311
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OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
3515 BROADWAY AVE

YANKTON, SD 57078


optimal level of functioning, thereby potentially
delaying a timely discharge.
111. Appropriately use and document
and failure to ensure privacy for patients.
Specific findings include:

treatment:
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
OATE
8 125 8125 (1.)

"ndividual staff review with patient will be
The policy ''Treatment Plan" will be reviewed
needed.
reatment and the policy change will be provided
o all staff. Treatment plans of current patients
will be reviewed by the unit Charge Nurses to
ensure inclusion interventions for providing
alternative forms of active treatment as needed.
A unit treatment log will be created to monitor
reatment participation and the provision of
alternative treatment options for patients who
refuse groups or are unable to participate.
activity logs weekly to ensure the provision of
alternative treatment options to patients. The
Addendum:
The Director of Clinical Services will report the 4/22/16
results of activity log audits to the Quality
compliance. Upon six months of 100%
A. Record Review
UX5311
Printed: 03/23/2016
FORM APPROVED

OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B. WING _ _ _ _ _ _ _ _ __
434003
(X4)1D
8 125
03/02/2016
PREFIX
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COMPLETED
3515 BROADWAY AVE

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Ill. Appropriately use and document
three (3) ofthree (3) discharged patients (X1, X2
continuously for almost 6 days. Safety {spitting)
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8 125 8125 (II)

~reated and implemented on Cedar 2 on
14/13/16. Self-paced treatment options will also
be implemented on Cedar 2 for patients that
were unable or did not wish to participate in
group activities.
nvolvement in group or individual treatment.
Staff education on activity schedule, activity
log, and self-paced treatment work will be
provided for all Cedar 2 staff.
Program Directors (2) will review unit activity
log weekly to ensure the providing of active
reatment. Findings of these reviews will be
provided to the Director of Clinical Services for
eview and corrective action. The Director of
Jclinical Services will report the findings to the
Quality Council until the Quality Council
ndicates standards are met and reporting is no
onger necessary.
~ddendum:
[Director of Clinical Services will report unit
iactivity log audit results to Quality Council
monthly. Expectation is 100% compliance.
Upon 6 months of 100% compliance, Quality
Jcouncil may indicate standards are met and
eporting to Quality Council is no longer
required.
14122/16

treatment:
A. Record Review
UX5311
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OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
3515 BROADWAY AVE

YANKTON, SD 57078


three (3) of three (3) discharged patients (X1. X2

treatment:
A. Record Review
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
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FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8 125 8125 (Ill)

The policies related to physical restraints will
be reviewed and revised to ensure patient
privacy when physical restraints are used. The
use of the safety frame (transport board) will be
discontinued. The safety frame will be removed
from policy. Safety hoods will be removed from
oolicy and use will be discontinued. The
presence of a staff member on the unit was
equired at all times when Cedar 2 is occupied
effective 3/2/16. Policy will be revised to add the
RN reviewing documentation, assessing patient
'or earliest release from restraint or seclusion
and documenting assessment at least hourly in
he medical record or more frequently depending
on patient need/condition or physician order.
The Physical Restraint/ Chemical Restraint/
Seclusion Monitoring Progress Note will be
revised to include a nursing assessment of
patient behavior at least hourly or more
Frequently depending on patient need/condition
or physician order.
(face shields and bite protection sleeves) will be
~he use of the protective equipment and policy
~rom restraint or seclusion by the Human Rights
!Specialist.
will review each episode of the use of restraint or
\Seclusion to ensure compliance. Any concerns
will be reported to the Medical Director and
~dministrator for corrective action. Daily staffing
\Sheets for Cedar 2 will be reviewed weekly by
~he Nurse Managers (2) to ensure staff presence
reviews will be report to the Director of Nursing
or designee weekly for review and corrective
action. Each of the responsible parties above will
report findings to the Quality Council until the
UX5311
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OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
8 125
03/02/2016

(X4)1D
PREFIX
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COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
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FORM APPROVED
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YANKTON, SD 57078


ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8 125 8125 (Ill) Continued

Addendum:
release at earliest time. Expectation is 100%
~ompliance. Upon 6 months of 100%
~ompliance, Quality Council May indicate
4/22/16
Addendum:
Council monthly.

treatment:
A. Record Review
UX5311
Printed:
OM8 NO. 0938-0391

A. BUILDING _ _ _ _ _ _ __
(X4)1D
8125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8125
1. Active sample patient 87 was admitted on

2/4/16, Psychiatric Evaluation dated 2/5/16
documented a diagnosis of "unspecified mood
disorder," "unspecified anxiety disorder," and
"unspecified personality disorder." Patient 87
problem was defined as "voices told pt. [sic] to
stay outside in the cold because the toilet was
going to blow up" and "refusing to take
medications."
2. Shift note dated 2/5/2016 at 10:03 p.m. and
written by HS Counselor states, "Patient spend
shift sitting in the day hall, nonverbal for the most
part". The registered nurse note for the same
date stated, "Patient refused all prescribed
medications and treatments this pm shift".
3. Nursing staff note dated 2/6/2016 at 9:49 a.m.
and written by a registered nurse stated, "Patient
spent the AM shift in bed". The pm shift 5:00
p.m., RN note stated "Patient spent the PM shift
in bed". "She/he has refused all medications
today as well as food". "Patient continues to lay
(sic) in bed and stare at the ceiling." There is no
indication that alternative interventions/modalities
were offered to the patient.
4. HS counselor note dated 2/7/2016 at 6:45
p.m., stated, "Pt spend (sic) the entire shift
resting in bed". Nursing staff note written by RN
at 2:59 p.m., stated, "Patient continues to refuse
to leave her/his room". The pm shift written by a
RN at 5:41 pm, stated, "Patient continues to stay
in her room although she/he has been up to the
desk and sitting up in the bed at times on the PM
shift."
5. Clinical Nurse Practitioner (CNP) note dated
2/8/2016 at 3:30 PM stated, "Patient refused to
UX5311
Printed:
OM8 NO 0938-0391
(X1) PROVIDERISUPPLIER/CLIA
A. BUILDING _ _ _ _ _ _ __
(X4)1D
8125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8125
come to rounds today". "According to staff,

she/he had still been not getting out of bed".
6. Recreational Therapy note dated 02/12/2016,
stated, "Patient refused all offered
Recreation groups during period 2/8/2016
through 02/12/2016
7. HS counselor noted dated 12/12/2016 at 8:46
PM, stated, "Pt spent the majority of the shift in
front of the television". "pt had minimal
interaction with staff or peers." "Pt kept to
her/himself".
8. Nursing staff note dated 2/23/2016 at 5.57 p.m.
and written by a RN, stated, "The patient has
been sitting in the day hall much of the day".
"He/she continues to refuse all medication
ordered".
9. Shift note dated 2/28/2016 at 2.11 p.m. and
written by a RN, stated, "Patient has been in
room in her/his bed all shift except for meals and
snacks". "Has not had interaction with peers or
staff'. "Refused to take all medications".
8. Observations
1. On 2/29/16 at 3:15 a.m. the surveyor observed
that active sample patient 87 was lying in bed
and not attending the scheduled leisure education
group that was in session on unit. No alternative
treatment was assigned and patient was allowed
to remain in the bed.
2. During observation on 3/2/16 at 9:30 a.m. the
surveyor again observed active sample patient 87
was lying in and not attending the scheduled
reality orientation group on unit.
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
{XS)
COMPLETION
DATE
8125
C. Interview
1. On 2/29/2016 at 4.05 p.m. RN6, charge nurse
on the unit was asked about active treatment for
sample patient 87, she stated "[Name of the
patient] refused to attend treatment meeting.
Does not participate in groups and usually in
her/his room most of the time." When asked
about alternative treatment for sample 87 the
nurse response was, "She/he is not allowed to
watch television".
2. On 3/2/2016 at 9.30 a.m. sample patient 87
was interviewed by the surveyor, stated, "She/he
have (sic) gone to a few activities but refused
most, I can't get up physically, maybe too
drugged to wake up, I feel stuck here". "I was
given the ok to go on off unit activity on 3/1/2016".
"I did not go today but maybe I will go tomorrow".
II. Ensure that patients were offered treatment
modalities:
A. Observations of the adult wing of C2 unit on
2/29/16 at4:10 p.m. and on 3/1/16 at 10:00 a.m.
revealed active sample Patient F5 in bed and the
other 3 adult patients sitting in front of the
television.
8. During a conference with facility staff on 3116
at 1 :30 p.m., the Director of Clinical Services
verified that there are currently no structured
on-going groups/activities for the patients on the
adult wing of the C2 Unit.
Ill. Appropriate use and documentation of
seclusion/restraint:
A. Seclusion of patients in unit areas:
UX5311
Printed:
03/23/2016
FORM APPROVED

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B. WING _ _ _ _ _ _ _ _ __
434003
B 125
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 125
1. During observations made on 2/19/16 at 4:00

p.m. and on 3/1/16 at 9:15 a.m., Patient F1 was
found by the surveyor alone on the adolescent
wing of Unit C2. Even though this ward could be
seen through the nursing station window, the door
to the office was locked; thereby the patient was
locked on the adolescent wing without a staff
member present.
2. During observations and interview with Patient
F1 at the above listed times, this patient
presented high levels of anxiety with
disorganized, erratic behaviors. While secluded
on this ward on 2/19/16, Patient F1was running
about the dayroom and jumping on and off a
chair.
3. During interview on 3/1/16 at 10:20 a.m.,
Mental Health Technician 8 reported that when
the patients {including active sample Patient F5)
on the adult wing are "resting in their rooms, we
{staff) go into the office {indicating the nursing
office adjacent to the patient dayroom)." When
asked if the door to the nursing station is locked,
she replied, "Yes, but we do our 15-minute
checks {patient monitoring)."
4. During interview on 3/1/16 at 10:30 a.m.
regarding the above findings, Nurse Supervisor 2
acknowledged that these patients had been
secluded since the office door was locked and
staff member{s) were not with the patients in the
ward area.
B. Ambulatory Restraints
1. Discharged Patient X 1
As documented in an RN note {9/22/16), Patient
X1 was transported from the hospital to another
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 125
town in wrist to waist and ankle restraints on

9/22/15. The physician's order on 9/22/15 at
10:18 a.m. was written as "Transport Restraint
placed for safety of staff + [and] pt [patient] for
discharge." There was no documented
physician's note to support the use of this
restraint based on an immediate threat to self or
others.
2. Discharged Patient X2
According to an RN note on 12/11 /15 at 10:55
a.m. Patient X2 was "escorted to hearing in
transport restraints due to history of aggressive
behaviors et (and} comments of not being able to
commit to safety." A counselor note on 12/11/15
stated, "Patient was transported in ambulatory
restraints due to ensure (sic} ensure safety of
staff, peers, property and patient." The
physician's order on 12/11/15 at 12:10 p.m. was
written as "Place pt (patient} in transport
restraints for off unit hearing." There was no
documented physician's note to support the use
of this restraint based on an immediate threat to
self or others.
3. Discharged Patient X3
a. According to a physician's history and physical
examination (7/3/15) and 15-minute monitoring
sheets, Patient X3 was placed in ambulatory
restraint (wrist to waist and ankle} restraints on
7/3/15 at 2:40 p.m. for "pulling out IVs et (and}
attempting to pull out G tube." An MD note
(7/3/15) stated that this patient was "placed on
ambulatory restraint at 1440 (2:40 p.m.} to
prevent immediate harm to self or others."
According to physician's orders, progress notes
and 15 minute monitoring sheets, this patient
remained in ambulatory restraints until 5:00 p.m.
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 125
COMPLETED
03/02/2016
(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


on 7/9/15. At times the patient was released from
ankle restraints, but remained in wrist to waist.
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
CATE
B 125
b. The first physician's order on 7/3/15 at 2:10

p.m. stated "Ambulatory Restraints wrist and
ankle." This order failed to include justification for
use of the restraints nor the time allowed in
restraints.
c. This patient was taken out in the hallways and
dayroom several times. During this time, his/her
privacy was not maintained as other patients
were in these Unit areas.
A counselor note on 7/5/15 stated, "Patient will
crawl moving his bottom in day hall." Another
counselor note on 7/5/15 at 9:54 p.m. stated
"Patient spent the evening scooting around the
day hall on his buttocks or lying on the floor in the
day hall."
A counselor note on 7/6/15 at 3:12 p.m.
documented, "While on the ground, the pt.
(patient) would scoot on his butt through the
hallways." Another counselor note on 7/6/15 at
10:06 p.m. stated "Pt. (Patient) continues to lay
(sic) on the floor of the day hall and slide around
using his hands."
On 7/8/15 at 4:04 p. m. an RN note stated "Pt.
(Patient) has been sitting in the day hall chair this
afternoon."
d. Some progress notes documented long
periods where the patient was calm, but still not
released from restraints:
1).An RN note on 7/6/15 at 4:56 a.m. stated "Pt.
(patient) has rested on & (and) off 7 hours (sic).
Pt has been lying (sic) on mat on floor in [his/her]
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING
(X4)1D
B 125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
8. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


room resting with eyes closed ... "
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 125
2).0n 7/8/15 at6:15 a.m. an RN note

documented, "Patient rested for 7 hours with eyes
closed ... Patient remains a (sic) 1: 1 while in
ambulatories waist, wrist and ankle.
3).0n 7/9/15 at 6:00 a.m. an RN note
documented "Pt (Patient) assessed for release
and pt cont (patient continued) to be unable to
commit to safety for self and others.
e. Review of the 15 minute monitoring sheets
revealed long periods of time, even on the first
day (7/3/15) that restraints were utilized, when
there was no documented patient behavior that
reflected immediate violence to self or others, yet
during these time periods the patient was not
released from the restraints.
C. Seclusion
1. Policy Review
a. Facility policy 5.2.3.3 titled "Seclusion Policy
(Medical Staff)", Revised 10/2/15, states, "It shall
be the policy of the SDHSC that the use of
seclusion may only be used to ensure the
immediate physical safety of a patient, a staff
member, or others and must be discontinued at
the earliest possible time".
b. Facility policy 5.2.3.3 titled "Seclusion Policy
(Medical Staff}", Revised 10/2/15, Procedure E
states, "Use of seclusion shall be ended at the
earliest possible time. A patient shall be released
form seclusion as soon as the patient is assessed
to no longer be a danger to self or others".
2. Record review
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
8 125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8125
a. According to facility's "Physical

restraint/chemical restraint/seclusion monitoring
progress note" dated 2/18/16, sample patient 87
was placed in seclusion of2/1/16 at 1650 (4:50
p.m.) for "forced AOL's (Activity of daily living):
combative & yelling". The patient continued on
and off for the next fifty-five minutes the behavior
of yelling/screaming/cursing and holding hands
out in front of her/him until 5:45 p.m. At 5.45 p.m.
to 6.45 p. m. the patient was described as sitting,
holding hands out in front of her/him, awake,
verbal communication to wall, standing, crying.
At 6.45 p.m. to 8.30 p.m. patient was described
sitting, verbal communication to wall, and
standing. At 8.30 p.m. patient was released from
seclusion.
b. According to facility's "Physical
was placed in seclusion of2/21/16 at 10.30 a.m.
for the administration of forced medication of
Ativan 1. mg for refusing medication p.o. (orally).
The patient continued on and off for the next
twenty minutes the behavior of
yelling/screaming/cursing, refusing redirect,
intrusive to peer until 11.00 a.m. At 11.00 a.m.
the patient was described as sitting, awake,
laughing/singing, crying and responding to
unseen stimuli. At 12.30 p.m. patient was
released from seclusion.
c. According to facility's "Physical
was placed in seclusion of2/17/16 at 10.25 a.m.
after the administration of forced medication of
Haldol 5mg and Ativan 2 mg IM (intermuscular).
At 10.14 a.m. patient became agitated and states
UX5311
Printed:

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 125
'Why did you use a dirty needle". "Pt. begins to

clench his fists and begins crying". "Pt. entered
recorders space with fists clenched in an
aggressive manner''. "Seclusion initiated as pt.
was a danger to others at 10.25 a.m.".
The patient continued on and off for the next five
minutes the behavior of pacing, crying, and
threating. At 10.30 a.m. the patient was
described as "eyes closed/respiration noted",
"lying on floor/mat/bed sitting, until 12.15 p.m.at
which time the patient was released from
seclusion.
d. According to facility's "Physical
was placed in seclusion of2/19/16 at 1725 (5.25)
p.m. after pt. approached and touch another
peer." "pt. noted to get agitated et. Become
verbally aggressive towards peer." Patient
become resistive and combative towards staff
during the administration of Haldol 5mg and
Ativan 2mg IM at 1724 (5.24).
At 1830 (6.30) p.m. the patient was described as
"eyes closed/respiration noted", "lying on
floor/mat/bed sitting, until 2125 (9.25) p.m.at
which time the patient was released from
seclusion.
e. According to facility's "Physical
was placed in seclusion of 2/20/16 at 0820 (8.22)
a.m. after patient refused to take medication
forced medication order was obtained for Zyprexa
10 mg IM and given. Patient struggled then
became aggressive with staff during medication
administration and was secluded at 8:22 a.m.
The patient continued on and off for the next
twenty-two the behavior of combative, standing,
UX5311
Printed:
OMB NO. 0938-0391

A. BUILDING _ _ _ _ _ _ __
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 125
and sitting until 8:45 a.m. At 9:00 am the patient

was described as "eyes closed/respiration noted
and lying on floor/mat/bed until 10:31a.m. At
10:31 a.m. the patent was released from
seclusion.
f. According to facility's "Physical
progress note" dated 2121/16, sample patient 810
was placed in seclusion of2/21/16 at 1108
(11 :08) a.m. Pt. has been hard to re-direct and
very intrusive with boundaries of staff and peers.
Pt. has increased self-talk, responding to unseen
stimuli, and cannot remain on topic. Pt. offered
oral PRN medications, and he/she refused them,
shoving the pills in the sock he/she was holding.
Physical hold was initiated and IM medication
was administered. P. was asked to stay in
his/her room to calm self, but became combative
and attempting to assault staff. Seclusion was
initiated at 11.1 O a.m. Starting at 11.15 staff
observation documented patient to be awake,
and lying on floor/mat/bed and other times sitting
until 1500 (3:00). At 1502 (3:02) patient was
released from seclusion.
3. Interview
On 3/2/2016 at 12:00 noon, the facility's Physical
progress note for sample patient 87 and B 10 was
reviewed with Nurse Supervisors 1 and 2. Both
Nurse Supervisor agreed with the finding that the
patients were kept in seclusion longer than
necessary. Nurse supervisor 1 stated "I see what
you are saying". Nurse supervisor 2 stated "yes",
they were no longer a danger to self and should
have been released earlier
D. Safety Hoods (spitting hoods)
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
PREFIX
TAG
B 125
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
03/02/2016
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 125
Safety/Protective Hoods, rather than defensive

gear used by staff, were unnecessarily used on
patients who demonstrated a propensity for
spitting on or biting staff. These restraints were
used based on a treatment plan entry and without
a physician's order for each occurrence.
1. Patient Review
a. Sample Patient H3
1). Review of active sample Patient H3's medical
record revealed an RN note (2/27/16 at 10:49
a.m.) stating that a "safety hood (spitting hood)
was applied" after the patient continued to
struggle with staff. There was no documentation
that this patient has been spitting or biting, nor
was there a physician's order for the use of this
restraint. An intervention assigned to a counselor
(SW paraprofessional) was added to Patient H3's
treatment plan on 2/8/16. This intervention stated
"Staff will apply protective hood when patient is
demonstrating imminent danger to self and
others."
Based on the patient's behavior as documented
in the medical record, it is not clear why this hood
was used on Patient H3 since there was failure to
document that s/he was spitting or biting.
b. Discharged PatientX1
As documented in an RN note on 9/22/15, "At
9:06 a.m. protective hood (spitting hood) was
placed per treatment plan as patient was trying to
spit and bite staff."
2. Policy Review
UX5311
Printed:

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


Hospital policy, "5.2.3.11 Protective Hood," states
"It shall be the policy of the SDHSC that a
protective hood may be used on a patient that
presents a demonstrated propensity to spit or bit
during restraint application or physical holds. The
protective hood shall be incorporated into the
patient's treatment plan prior to use if the
treatment team believes the demonstrated
behavior may occur in future restraint
application/physicals holds. Demonstrated
behavior during past hospitalizations or in other
treatment centers may be considered by the
treatment team."
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 125
Even though the protective hood is a restraint,

this policy failed to ensure that a physician's order
was required.
E. Transport Boards (safety frame), rather than

beds, were used to restrain patients. Use of the
transport board for continued restraint may result
in physical complications for the patient.
1. Review of active sample Patient H3's medical
record revealed an RN note (2/27/16 at 10:49
a.m.) stating "Safety frame applied at 1323 (1 :23
p.m.)" after throwing a chair, screaming and
hitting a staff member. Patient was released from
"safety frame" at 2: 10 p.m. The physician's order
stated, "Safety frame until no longer danger to
self/others, not to exceed 2 hours." Review of the
monitoring sheet revealed that the only behavior
reflecting that the patient was upset while on the
transport board from 1:21 until 2:10 p.m. was
"crying, yelling/screaming cursing" at 1 :30 p.m.
2. Observation of the transport board used by this
facility on the morning of 3/2/16 revealed a
transport board made by the Humane Restraint
Company called a "transboard." It was a narrow,
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 125
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


flat board made of hard material. This board was
meant for brief use, rather than longer periods of
time.
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 125
3. During interview on the morning of 312/16, the

Director of Clinical Services reported that the
hospital has been using the board for restraint as
the hospital does not have restraint beds.
B 136 482.62 SPECIAL STAFF REOS FOR PSYCH
HOSPITALS
The hospital must have adequate numbers of
qualified professional and supportive staff to
evaluate patients, formulate written, individualized
comprehensive treatment plans, provide active
treatment measures and engage in discharge
planning.

review, the facility failed to provide adequate
numbers of registered nurses (RNs) on the night
shift for six (6) of eight (8) patient care units (A 1,
81, 82, C1, 01 and 02). There was One (1) RN
(Registered nurse) covering two (2) locked units,
leaving one of the unit without a professional
nurse to assess, monitor and supervise patient
care and paraprofessionals (Mental Health
Technicians) for a period of approximately four (4)
hours. Based on "Patient Need Assessment"
completed by the unit's Nurse manager indicated
a high acuity level on each unit for two (2) MHT to
closely monitor the patients and do all required
paperwork for the unit in the absence of the RN.
This pattern of staffing creates a potential safety
risk for all the patients on all six (6) locked units.
(Refer to 8150)
B 136 8136
Each licensed unit will be staffed with at least 1
RN per unit on each shift to ensure adequate RN
$tatting.
~tatting patterns for RN staff will be reviewed
and revised by the Director of Nursing to ensure
RN coverage on each licensed unit. The staffing
suide for the hospital will be revised to reflect
adequate staffing provided for each unit.
rrhe daily staffing sheets will be reviewed weekly
by the Nurse Managers (2) to ensure adequate
$tatting levels. The results of these reviews will
be reported to the Director of Nursing or
k:lesignee weekly to address any problems noted.
irhe DON or designee will report findings of the
eviews to the Quality Council until the Quality
K;ouncil indicates standards are met and
~ddendum:
iThe DON or designee will report staffing audits
to Quality Council monthly. The expectation is
100% compliance. Upon 6 months of 100%
compliance Quality Council may indicate
14/22/16
In addition, there was failure to provide adequate

UX5311
lfcontinuationsheetPage 31 of43
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 136
3515 BROADWAY AVE

YANKTON, SD 57078


clinical leadership by medical and nursing
leadership to monitor and evaluate care to
patients. This resulted in patients receiving
inappropriate care and the lack of monitoring of
inpatient care by the Medical Director as
documented in 8144 and lack of supervision of
active nursing care delivered as documented in
8148.
B 144 482.62(b)(2) MEDICAL STAFF

The director must monitor and evaluate the
quality and appropriateness of services and
treatment provided by the medical staff.

review, the Clinical Director failed to:
I. Provide psychiatric evaluations that reported
orientation, memory functioning and/or intellectual
functioning in measurable, behavioral terms for
six (6) of eight (8) sample patients (81, 87, 05,
F1, F5 and H3). This compromises the database
from which diagnoses are determined and from
which changes in response to treatment
interventions may be measured. (Refer to 8116)
II. Provide psychiatric evaluations that included
an assessment of patient assets in descriptive
fashion for four (4) of eight (8) sample patients
(87, 810, F1 and F5). The failure to identify
patient assets impairs the treatment team's ability
to choose treatment modalities that utilize the
patient's attributes in the therapy. (Refer to B 117)
Ill. Ensure that treatment plans were developed
by professional team members, rather than
Counselors (Social Service paraprofessionals).
This inappropriate delegation of responsibility for
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8136 8144(1)
~ template for completion of psychiatric
evaluations was created to include orientation,
memory functioning and/or intellectual
runctioning in measurable, behavioral terms.
ifhe policy "Psychiatric Evaluation" was reviewed
o ensure inclusion of orientation, memory
~unctioning and/or intellectual functioning in
measurable, behavioral terms.
B 144 Education will be provided to all Psychiatry staff
pn the standards for psychiatric evaluation and
he template for completion. Monthly meetings
between the Medical Director and Psychiatric
$taff will be scheduled.
evaluations each month for inclusion of
orientation, memory functioning and/or
erms. The Director of HI/QM will report findings
weekly to the Medical Director. The Medical
Director will meet monthly with Psychiatric Staff
o review and continue to educate to ensure
pompliance. Psychiatric staff performance out of
compliance will be referred to Medical Executive
committee and President of Medical Staff for
corrective actions.
~ddendum:
iThe Director of HI/QM will report findings of
the Quality Council. The expectation is 100%
~ompliance. Upon 6 months of 100 %
~ompliance, the Quality Council may indicate
~ddendum:
ifhe Director of HI/QM will report findings of
raudits of Psychiatric Evaluations for inclusion of
prientation, memory functioning and/or
terms.to the Quality Council monthly.
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
3515 BROADWAY AVE

YANKTON, SD 57078


documented in 8144 and lack of supervision of
8148.


F1, FS and H3). This compromises the database
interventions may be measured. (Refer to 8116)
(87, 810, F1 and FS). The failure to identify
Ill. Ensure that treatment plans were developed
COMPLETED
03/02/2016

(X4)1D
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TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
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DEFICIENCY)
(X5)
COMPLETION
DATE
8136 8144(11)
~ template for completion of psychiatric
~valuations was created to include an
assessment of patient assets in descriptive
~ashion.
:rhe policy "Psychiatric Evaluation" was reviewed
lo ensure inclusion of an assessment of patient
assets in descriptive fashion.
Education will be provided to all Psychiatry staff
B 144 bn the standards for psychiatric evaluation and
he template for completion. Monthly meetings
between the Medical Director and Psychiatric
staff will be scheduled.
evaluations each month for inclusion of an
assessment of patient assets in descriptive
'ashion. The Director of HI/QM will report
Jindings weekly to the Medical Director. The
Medical Director will meet monthly with
Psychiatric Staff to review and continue to
educate to ensure compliance. Psychiatric staff
performance out of compliance will be referred to
Medical Executive committee and President of
Medical Staff for corrective actions.
Addendum:
'ashion to the Quality Council. The expectation
is 100% compliance. Upon 6 months of 100 %
~ddendum:
[fhe Director of HI/QM will report findings of
~ashion to the Quality Council monthly.
UX5311
Printed:
DEPARTMENT OF HEALTHAND HUMAN SERVICES

OMB NO. 0938-0391

A. BUILDING _ _ _ _ _ _ __
B 136
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


documented in B 144 and lack of supervision of
8148.

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 136 8144 (Ill)

rThe treatment plan format will be revised to
reflect the creation of the treatment plan by
icensed members of the treatment team.
rThe policy "Treatment Plan" will be reviewed and
revised to define the treatment team members
responsible for the creation of the treatment plan
ias licensed staff in the disciplines of Psychiatry,
Nursing, Social Work, Occupational Therapy,
Physical Therapy, Dietetics, and Speech
B 144 rTherapy. The Class Specification for the position
Human Services Counselor will be reviewed and
evised. The development of patient treatment
will be removed from the job function.
Education on the new treatment plan format and
policy revision will be provided to all staff.

F1, F5 and H3). This compromises the database
interventions may be measured. (Refer to B 116)
(87, 810, F1 and F5). The failure to identify

patient treatment plans to ensure the treatment
plans were created and developed by licensed
members of the treatment team. Nurse
Managers will report the findings of these
reviews to the Director of Nursing or designee
"indings to the Quality Council until the Quality
Addendum:
with treatment plans created and developed by
111. Ensure that treatment plans were developed

UX5311
Printed:

OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
8 144
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
8. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


patient treatment planning to non-professional
unlicensed team members resulted in treatment
plans that were not individualized based on
individual patient needs. (Refer to 8118)
IV. Develop treatment plans that clearly
patients (dates of plans in parentheses): 87,
810, D5, E10, F1, F5, G2 and H3. Instead most
of the interventions for these professionals were
routine, generic discipline functions that lacked
focus for treatment. This resulted in treatment
plans that failed to reflect a comprehensive,
integrated, individualized approach to
multidisciplinary treatment. (Refer to 8122)
V. Ensure that responsibility for the
implementation and evaluation for the majority of
treatment plan interventions were assigned to a
Counselor (Social Service paraprofessional),
rather than to a professional treatment team
member. This deficiency resulted in an
inappropriate delegation of responsibility for
patient treatment to non-professional unlicensed
team members and confusion in the
responsibilities of the team. (Refer to 8123)
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8 144 IB144(1V)
rT"he treatment plan format for all patient
lreatment plans will be changed to clearly
indicate the involvement of professional staff.
rT"he new format allows for individualization
specific to patient's assessed strengths, needs,
and interests.
Education will provided to all staff on treatment
planning, the individualization of treatment plans,
and the roles of professional staff in the
reatment planning process.
delineation of interventions for professional staff.
Nurse Managers will report the findings of these
eviews to the Director of Nursing or designee
findings to the Quality Council until the Quality
Addendum:
with treatment plans defined proper delineation
of interventions for professional staff. Upon six
months of 100%, the Quality Council may
indicate standards are met and reporting to
VI. Ensure that patients who were housed and

dependency rehabilitation services to the unit
providing services for the diagnosis and treatment
of mental illness. This practice results in
improper use of areas/services certified for the
delivery of acute psychiatric care and impacts the
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
3515 BROADWAY AVE

YANKTON, SD 57078


810, 05, E10, F1, F5, G2 and H3. Instead most
COMPLETED
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434003
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FORM APPROVED
ID
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DEFICIENCY)
(X5)
COMPLETION
DATE
8 144 8144 (V)

lreatment plans will be revised to include a
~ignature line on the Master Treatment Plan
(MTP) and an initial box with responsible
ctiscipline with each intervention. All patients will
eceive an Initial Treatment plan upon admission
which includes a signature from the responsible
professional discipline.
and revised to ensure the appropriate level of
esponsibility for the identified problems, goals
and interventions was assigned to the
appropriate professional staff member of the
treatment team.
Education on treatment planning process, the
policy change, and the roles of each treatment
earn member will be provided to all staff.
patient treatment plans to ensure the
responsibilities of each member of the treatment
earn are evident and appropriate for the level of
licensure.
Nurse Managers will report the findings of
hese reviews to the Director of Nursing or
designee weekly for review and corrective
actions. The DON or designee will report the
esults of these findings to the Quality Council
Addendum:
The DON or designee will report the results
reatment team audits to the Quality Council
with treatment team members have appropriate
levels of responsibility with appropriate licensure.
Upon six months of 100%, the Quality Council
may indicate standards are met and reporting to
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
8 144
3515 BROADWAY AVE

YANKTON, SD 57078


810, D5, E10, F1, F5, G2 and H3. Instead most
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
8 144 8144 (VI)

reatment.
Each patient residing on the certified unit who
are receiving chemical dependency treatment
will be assessed by the treatment team.
Referrals and discharge plans to the appropriate
level of care will be made and carried out.
The policy and procedure Patient Unit
combinations to ensure proper licensure for
~mbinations will be reported to the Director of
K:}uality Management.
Checklist to ensure that patients who were
'3cute psychiatric care are receiving services for
~he diagnosis and treatment of mentally ill
persons. The Director of HI/QM will report the
~ndings of these reviews to the Quality Council
~ddendum:
rrhe Director of Health Information and Quality
tompliance with no combining of units with
pompliance, the Quality Council may indicate
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING
(X4)1D
8 144
3515 BROADWAY AVE

YANKTON, SD 57078


quality treatment of patients receiving psychiatric
services. (Refer to 899)
VII. Provide active individualized psychiatric
81251)
VIII. Ensure that patients in one (1) of eight (8)
Unit C2. Failure to provide sufficient hours of
active treatment prevents patients from achieving
their optimal level of functioning, thereby
potentially delaying a timely discharge. (Refer to
812511)
IX. Appropriately use and document
restraints. Patients were secluded/restrained
without documented justification based on
changing behaviors and there was failure to use
proper release criteria for seclusion. Patients
03/02/2016
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TAG
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COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
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FORM APPROVED
ID
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DEFICIENCY}
(XS)
COMPLETION
DATE
8 144 8144 (VII)

individual staff review with patient will be
needed.
~reatment and the policy change will be provided
~o all staff. Treatment plans of current patients
Will be reviewed by the unit Charge Nurses to
ensure inclusion interventions for providing
alternative forms of active treatment as needed.
~ unit treatment log will be created to monitor
~reatment participation and the provision of
alternative treatment options for patients who
refuse groups or are unable to attend.
ltreatment, the unit activity log, and the policy
change will be provided to all staff.
activity logs weekly to ensure the provision of
alternative treatment options to patients. The
~ddendum:
hhe Director of Clinical Services will report
UX5311
Printed:
03/23/2016
FORM APPROVED

OM8 NO 0938-0391
A. BUILDING
8144
3515 BROADWAY AVE

YANKTON, SD 57078


81251)
812511)
03/02/2016

(X4)1D
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B. WING _ _ _ _ _ _ _ _ __
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(X3) DATE SURVEY
ID
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DEFICIENCY)
(X5)
COMPLETION
DATE
8 144 8144 (VIII)

created and implemented on Cedar 2 on
14113/16.
Self-paced treatment options with individual
review with staff will be implemented on Cedar 2
~or patients that were unable or did not wish to
participate in group activities. Self-paced
reatment options will be implemented on Cedar
2 for patients that are unable or did not wish to
participate in group activities.
involvement in group or individual treatment.
Program Director will review unit activity log
weekly to examine the provision of active
reatment using an audit form. Findings of these
reviews will be provided to the Director of
Clinical Services for review and corrective
action. The Director of Clinical Services will
Addendum:
The Director of Clinical Services will report
results of Cedar 2 active treatment audits to the
Quality Council monthly. The expectation is
~mpliance, the Quality Council may indicate
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
3515 BROADWAY AVE

YANKTON, SD 57078


81251)
812511)
COMPLETED
03/02/2016

(X4)1D
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(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
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(X5)
COMPLETION
DATE

DEFICIENCY)
8 144 8144 (IX)

The policies related to physical restraints will be
reviewed and revised to ensure patient privacy
When physical restraints are used. The use of
lhe safety frame (transport board) will be
~iscontinued. The safety frame will be removed
from policy. Safety hoods will be removed from
policy and use will be discontinued. The
presence of a staff member on the unit was
required at all times when Cedar 2 is occupied
effective 3/2/16. Policy will be revised to add the
RN reviewing documentation, assessing patient
for earliest release from restraint or seclusion
and documenting assessment at least hourly in
he medical record or more frequently depending
on patient need/condition or physician order.
The Physical Restraint/ Chemical Restraint/
Seclusion Monitoring Progress Note was revised
to include a nursing assessment of patient
behavior at least hourly or more frequently
depending on patient need/condition or
physician order.
(face shields and bite protection sleeves)will be
he use of the protective equipment and policy
rrom restraint or seclusion by the Human Rights
Specialist.to Quality Council is no longer
required.
will review each episode of the use of restraint or
seclusion to ensure compliance. Any concerns
will be reported to the Medical Director and
Administrator for corrective action. Daily staffing
sheets for Cedar 2 will be reviewed weekly by
he Nurse Managers (2) to ensure staff presence
reviews will be report to the Director of Nursing
or designee weekly for review and corrective
action. Each of the responsible parties above will
UX5311
3'fb
Printed:

OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
8 144
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B.WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


81251)
8125 II)
ID
PREFIX
TAG

(XS)
COMPLETION
DATE

DEFICIENCY)
8 144 8144 (IX) continued

eport findings to the Quality Council until the
Addendum:
release at earliest time. Expectation is 100%
~ompliance. Upon 6 months of 100%
~mpliance, Quality Council May indicate
4/22/16
\Addendum
Council monthly.

UX5311
3lf c.
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 144
3515 BROADWAY AVE

YANKTON, SD 57078


were secluded alone and with others on wards.
One (1) of three (3) discharged patients (X3) was
in ambulatory restraints continuously for almost 6
days. Safety (spitting) hoods, rather than
defensive gear for staff, were used on patients,
sometimes without proper justification. Transport
boards were used inappropriately as restraint
beds. These deficiencies resulted in safety risks,
violations of the patients' right to be free from
undue restraint and failure to ensure privacy for
patients. (Refer to B 125 Ill)
B 147 482.62(d)(1) NURSING SERVICES

The director of psychiatric nursing services must
be a registered nurse who has a master's degree
in psychiatric or mental health nursing or its
equivalent from a school of nursing accredited by
the National League for Nursing, or be qualified
by education and experience in the care of the
mentally ill.

Director of Nursing (DON) failed to meet the
educational, or ongoing consultation and or
training requirements necessary for her
administrative position as Executive Nurse within
this facility. This hinders direction to the nursing
department and the level of care provided by
nursing personnel.
Findings include:
A. Review of the Nursing Director's (DON)
resume revealed that the DON did not have a
Master's Degree in Psychiatric/Mental Health
Nursing nor was in consultation with a Master's
Degree Psychiatric/Mental Health Nurse.
Ongoing training was not reflective either.
03/02/2016
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COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
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DEFICIENCY)
(X5)
COMPLETION
DATE
B 144 8147
The DON will be provided consultation with a
Master's of Psychiatric Nursing prepared RN as
needed. Content and goals of each consultation
will be documented and submitted by the
~nsultant to the hospital administrator.
Areas of focus will include treatment plan
kjocumentation and review, staffing plan
adherence, adherence to programming plan,
~valuation of nursing care provided at HSC and
pther issues as needed.
rThe DON will participate in Psychiatric Nursing
B 147 rrraining annually.
Documentation of consultation with Master's of
Psychiatric Nursing prepared RN and annual
training will be reviewed by the Administrator
and documented in the DON's personnel file.
~ddendum:
rrhe DON will be provided bi-monthly
consultation with a Master's of Psychiatric
Nursing prepared RN in addition to as needed
consultation. The DON will participate in at least
8 hours of Psychiatric Nursing Training annually.
Administrator will report to Quality Council audit
of DON consultation and annual education at
next monthly Quality Council meeting and
quarterly after that. Expectation is 100%
compliance in consultation hours and 100%
compliance for annual education. Administrator
will continue to report to Quality Council
quarterly of monthly consultation compliance.
Upon two reports of 100% compliance, Quality 4/22/16
Council may indicate standards are met and
eporting to Quality Council is no longer
required.
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 147
03/02/2016

(X4)1D
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COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


B. Interview
In an interview on 2/1/16 at 2:15 P.M. with the
Hospital Administrator, the credentials of the DON
were discussed. The Administrator agreed that
the DON did not have a Master's Degree in
PsychiatridMental Health Nursing. The
Administrator stated that the hospital has a
contract with a group that includes a Nurse with a
Master's Degree in Psychiatric Mental Health, but
the relationship between this nurse and the DON
does not reach the consultation level. In addition,
he stated that he was not aware of any ongoing
training currently pursued by the DON.

The director must demonstrate competence to
participate in interdisciplinary formulation of
individual treatment plans; to give skilled nursing
care and therapy; and to direct, monitor, and
evaluate the nursing care furnished.

Nursing Director failed to:
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 147 8148
I. The treatment plan format for all patient
treatment plans will be changed to clearly
indicate the involvement of RN staff. The new
format allows for individualization specific to
patient needs and strengths.
Education will be provided to all RNs staff on
treatment planning, the individualization of
treatment plans, and the roles of professional
$taff in the treatment planning process.
delineation of interventions for RN staff. Nurse
Managers will report the findings of these
reviews to the Director of Nursing or designee
8 148 DON or designee will report the results of these
findings to the Quality Council until the Quality
with treatment plans created and developed by
I. Ensure nursing interventions were included in

the Master Treatment Plans (MTPs) based on the
individual needs of eight (8) of eight (8) active
sample patients (87, 810, D5, E10, F1, F5, G2
and H3). This failure resulted in absence of
specific plans to direct nursing personnel in the
implementation, evaluation and revision of care to
reflect progress/lack towards recovery. (Refer to
8122)
II. Ensure patients in seclusion/restraint whose
behavior no longer indicates they are a danger to
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
(X4)1D
B 147
3515 BROADWAY AVE

YANKTON, SD 57078


B. Interview
In an interview on 2/1/16 at 2:15 P.M. with the
Hospital Administrator, the credentials of the DON
were discussed. The Administrator agreed that
the DON did not have a Master's Degree in
Psychiatric/Mental Health Nursing. The
Administrator stated that the hospital has a
contract with a group that includes a Nurse with a
Master's Degree in Psychiatric Mental Health, but
the relationship between this nurse and the DON
does not reach the consultation level. In addition,
he stated that he was not aware of any ongoing
training currently pursued by the DON.

The director must demonstrate competence to
participate in interdisciplinary formulation of
individual treatment plans; to give skilled nursing
care and therapy; and to direct, monitor, and
evaluate the nursing care furnished.

Nursing Director failed to:
I. Ensure nursing interventions were included in
the Master Treatment Plans (MTPs) based on the
individual needs of eight (8) of eight (8) active
sample patients (87, 810, 05, E10, F1, F5, G2
and H3). This failure resulted in absence of
specific plans to direct nursing personnel in the
implementation, evaluation and revision of care to
reflect progress/lack towards recovery. (Refer to
8122)
II. Ensure patients in seclusion/restraint whose
behavior no longer indicates they are a danger to
03/02/2016
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TAG
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COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 147 13148 (II.)

The policies related to physical restraint will be
revised to add the RN reviewing documentation,
assessing patient for earliest release from
restraint or seclusion and documenting
assessment at least hourly in the medical record
or more frequently depending on the patient
need/condition or physician orders. The
Physical Restraint/ Chemical Restraint/
Seclusion Monitoring Progress Note will be
revised to include a nursing assessment of
patient behavior at least hourly or more
'requently depending on the patient
need/condition or physician orders.
Education will be provided to all staff regarding
documentation and policies revisions.
8 148 The Nurse Managers will review Physical
Restraint/Chemical Restraint/Seclusion
Monitoring Progress Note following each
restraint and seclusion event to ensure RN
assessment is completed at least hourly. Any
documentation out of compliance will be
reported to CRN for corrective action with the
RN failing to meet assessment standard. NM
will report compliance to DON or designee who
will report to Quality Council until QC no longer
'eels necessary to report.
Addendum:
The DON or designee will report audit of
Physical Restraint/Chemical Restraint/Seclusion
Monitoring Progress Note to ensure appropriate
and timely assessment by RN throughout
seclusion and restraint event. Expectation is
compliance, Quality Council may indicate
~ddendum:
DON or designee will report findings of audits to
~he Quality Council Monthly.
UX5311
Printed:
OMB NO 0938-0391
A. B U I L D I N G - - - - - - - -
B 148
03/02/2016
(X4)1D
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434003
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FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


self or others are release at the earliest possible
time. (Refer to 8125)
Ill. Provide adequate numbers of registered
nurses (RNs) on the night shift for six of eight
patient care units (A1, 81, 82, C1, 01 and 02).
There was 1 RN (Registered nurse) covering two
locked units, leaving one of the unit without a
professional nurse to assess, monitor and
supervise patient care and paraprofessionals
(Mental Health Technicians) for a period of
approximately four hours. Based on "Patient
Need Assessment" completed by the unit's Nurse
manager indicated a high acuity level on each
unit for two MHT to closely monitor the patients
and do all required paper work for the unit in the
absence of the RN. This pattern of staffing
creates a potential safety risk for all the patients
on all six locked units. (Refer to B 150)

There must be adequate numbers of registered
nurses, licensed practical nurses, and mental
health workers to provide the nursing care
necessary under each patient's active treatment
program.
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 148 8148 (Ill)

staffing.
Staffing patterns for RN staff will be reviewed
and revised by the Director of Nursing to ensure
guide for the hospital will be revised to reflect
The daily staffing sheets will be reviewed weekly
staffing levels. The results of these reviews will
designee weekly to address any problems noted.
The DON or designee will report findings of the
Addendum:
The DON or designee will report staffing audits
B 150 o Quality Council monthly. The expectation is
100% compliance with having each unit staffed
With an RN for all shifts. Upon 6 months of
100% compliance, Quality Council may indicate
~tandards are met and reporting to Quality
\Council is no longer required.
4/22/16

Nursing Director failed to provide adequate
81, 82, C1, 01 and 02). There was 1RN
(Registered nurse) covering two locked units,
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 148
3515 BROADWAY AVE

YANKTON, SD 57078


self or others are release at the earliest possible
time. (Refer to 8125)
Ill. Provide adequate numbers of registered
nurses (RNs) on the night shift for six of eight
patient care units (A1, 81, 82, C1, 01 and 02).
There was 1 RN (Registered nurse) covering two
locked units, leaving one of the unit without a
professional nurse to assess, monitor and
supervise patient care and paraprofessionals
(Mental Health Technicians) for a period of
approximately four hours. Based on "Patient
Need Assessment" completed by the unit's Nurse
manager indicated a high acuity level on each
unit for two MHT to closely monitor the patients
and do all required paper work for the unit in the
absence of the RN. This pattern of staffing
creates a potential safety risk for all the patients
on all six locked units. (Refer to B 150)

There must be adequate numbers of registered
nurses, licensed practical nurses, and mental
health workers to provide the nursing care
necessary under each patient's active treatment
program.

Nursing Director failed to provide adequate
81, 82, C1, 01 and 02). There was 1RN
(Registered nurse) covering two locked units,
COMPLETED
03/02/2016
STREET ADDRESS, Cl1Y, STATE, ZIP CODE
(X4)1D
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(X5)
COMPLETION
DATE
B 148
8150
~taffing.
$taffing patterns for RN staff will be reviewed
B 150 ~nd revised by the Director of Nursing to ensure
guide for the hospital will be revised to reflect
rrhe daily staffing sheets will be reviewed weekly
$taffing levels. The results of these reviews will
~esignee weekly to address any problems noted.
rrhe DON or designee will report findings of the
~ddendum:
rrhe DON or designee will report staffing audits
lo Quality Council monthly. The expectation is
100% compliance with having each unit staffed
With an RN for all shifts. Upon 6 months of
100% compliance, Quality Council may indicate
14122/16
UX5311
Printed:
03/23/2016
FORM APPROVED

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B. WING _ _ _ _ _ _ _ _ __
434003
(X4)1D
B 150
03/02/2016
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TAG
(X3) DATE SURVEY

COMPLETED
3515 BROADWAY AVE

YANKTON, SD 57078


hours. Based on "Patient Need Assessment"
completed by the unit's Nurse manager indicated
a high acuity level on each unit for two MHT to
closely monitor the patients and do all required
paper work for the unit in the absence of the RN.
This pattern of staffing creates a potential safety
risk for all the patients on all six (6) locked units.
ID
PREFIX
TAG

DEFICIENCY)
()(5)
COMPLETION
DATE
8150
Findings include:
A. Overview Information:
A review of the "Minimum Therapeutic Staffing
and Emergency Staffing Guidelines" for the
facility, which was provided by the Nurse
manager, showed the "Acute Admission
Program" (A1, A2, 81, C1 and C2) minimum
number of RN staff for the night shift would be
three (3) RNs with two units sharing one RN and
two units have one RN on each unit. The
Adolescent units (82, 01 and 02) required
minimum RN staffing of .5 RN (1 RN supervising
two (2) units).
B. Specific Findings:
1. Aspen1 (A 1) is a 15-bed acute admission unit
for male and female adults
a. Review of the Patient Nursing Needs
Assessment completed by an RN on the first day
of the survey (2/29/16) revealed that there was a
census of 11 patients - 3 patients required
diabetic checks, 1 IV's, 9 patients required skin
care, and 1 Detox. Protocol, 1 patient was
potentially assaultive, 2 patients were actively
assaultive, 1 patient was a low risk for suicide, 3
patients were actively experiencing
hallucinations/delusions, 1 patient took
medications reluctantly, and 2 patients have
UX5311
Printed:
03/23/2016
FORM APPROVED

OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B. WING _ _ _ _ _ _ _ _ __
434003
(X4)1D
8 150
03/02/2016
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
8150
medication problems (forced/non-voluntary).

b. The "Direct Nursing Staffing Form" completed
by the Nurse Supervisor for 7 days including the
first day of the survey (2/29/16), revealed that the
night shift RN was assigned to supervise two
units A 1 and 81 and had no replacement when
she/he had to leave one unit to supervise the
other unit.
On 2/27/16 there was only 1 RN assigned on the
night shift to supervise A 1 and 81.
2. 8irch1 (81) is a 15-bed acute unit for male and
female adults.
of the survey (2/29/16) reveled that there was a
census of 11 patients - 1 patient required seizure
precautions, 3 patients required skin care, 5
patients were potentially assaultive, 1 patient was
actively assaultive, 4 patients were low risk for
suicide precautions, 4 patients were actively
experiencing hallucinations/delusions, 2 patients
took medications reluctantly, and 1 patient have
medication problems
night shift to supervise 81 and C1.
UX5311
Printed:
OM8 NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


night shift to supervise 81 and A 1.
ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
CATE
8150

3. 8irch2 (82) is a 15 bed acute adolescent acute
unit for male and female
census of 9 patients - 1 patient required dressing
changes, 1 patient required skin care, and 2
patients were on intermediate risk suicide.
by the Nurse Supervisor for 7 days including the
units 82 and C1 and had no replacement when
she/he had to leave one unit to supervise the
other unit.
4. Cedar1 (C1} is a 23-bed acute admission unit

for male and female adults.
of the survey (2/29/16) revealed that there was a
census of 12 patients - 2 patients required
diabetic checks, 3 patients required seizure
precautions, 4 patients required skin care, and 1
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
COMPLETED
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078


required neurological checks, 4 patients were
potentially assaultive, 1 patient was on
intermediate risk suicide, 4 patients were low risk
for suicide, 4 patients were actively experiencing
hallucinations/delusions, 2 patients took
medications reluctantly, and 4 patients have
medication problems ( forced/non-voluntary).
ID
PREFIX
TAG

DEFICIENCY)
(XS)
COMPLETION
DATE
B 150

by the Nurse manager for 7 days including the
units C1 and 81 (Birch 1) and had no
replacement when she/he had to leave one unit
to supervise the other unit.
night shift to supervise C1 and 81.
5. Oak 1 (01) is a 20-bed Adolescent
Intermediate unit for male and female unit.
UX5311
Printed:

OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 150

census of 15 patients - 1 patient required seizure
precautions, 2 patients were potentially
assaultive, and 1 patient took medications
reluctantly.
night shift to supervise 01 and 02.
6. Oak 2 (02) is a 16-bed acute unit for male and
female adults.
census of 7 patients - 1 patient required diabetic
check, 2 patients were potentially assaultive, 2
patients were low risk for suicide precautions, 2
patients were actively experiencing
hallucinations/delusions, 1 patients took
medications reluctantly.
C. Interview
UX5311
Printed:
OMB NO 0938-0391
A. BUILDING _ _ _ _ _ _ __
B 150
03/02/2016

(X4)1D
PREFIX
TAG
(X3) DATE SURVEY

COMPLETED
B. WING _ _ _ _ _ _ _ _ __
434003
03/23/2016
FORM APPROVED
3515 BROADWAY AVE

YANKTON, SD 57078

ID
PREFIX
TAG

DEFICIENCY)
(X5)
COMPLETION
DATE
B 150
1. In an interview on 2129/16 at 4:25 P.M., with

the RN-6 charge nurse on the unit Aspen 2 unit
(A2); overall RN staffing was discussed and she
indicated "Nurses may share two units on the
night shift and the night shift nurse do not have a
lunch break."
2. In an interview on 3/1/16 at 1:45 P.M. with the
Nurse Supervisor 1 for the Adolescents program
and Nurse Supervisor 2 the for the Acute
Admission Program unit, the staffing information
from the direct nursing staffing form were
discussed. They both agreed that one RN is
schedule on the night shift to cover two units.
When the RN is present on one unit, the other
unit has no RN coverage. In addition, they
agreed that only two MHT is left on the unit when
the RN is on one of two of the units assigned.
When asked if coverage was adequate for the
unit when the RN is absent, they both stated "no."
UX5311

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CMS HSC Inspection

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DEPARTMENT OF SOCIAL SERVICES

HUMAN SERVICES CENTER

April 13, 2016

CMS - Certification & Enforcement Branch

Dear Ms. Jewell:

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER

(X3) DATE SURVEY

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES

B 000 INITIAL COMMENTS

This Condition is not met as evidenced by:

POST OFFICE BOX 7600

he plan of correction completion and monitoring

dolescent patients receiving chemical

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

If continuation sheet Page 1 of 43

STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER

(X3) DATE SURVEY

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES

B 000 INITIAL COMMENTS

POST OFFICE BOX 7600

B 000 8098 (continued from page 1)

irhe Director of Health Information and Quality

The hospital must meet all special provisions

This Condition is not met as evidenced by:

Psychiatric hospitals must be primarily engaged

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

If continuation sheet Page 1 of 43

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES

Continued From page 1

This Standard is not met as evidenced by:

STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER

(X3) DATE SURVEY

POST OFFICE BOX 7600

If continuation sheet Page 2 of 43

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES

Continued From page 2

E. During interview on 2/29/16 at 3:20 p.m., RN4

This Condition is not met as evidenced by:

STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER

(X3) DATE SURVEY

POST OFFICE BOX 7600

B 099 8103 (1.)

If continuation sheet Page 3 of 43

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES

8 103 Continued From page 3

FORM CMS-2567(02-99) Previous Versions Obsolete

STREET ADDRESS, CITY, STATE, ZIP CODE

SOUTH DAKOTA HUMAN SERVICES CENTER

(X3) DATE SURVEY

POST OFFICE BOX 7600

8 103 8103 (11.)

If continuation sheet Page 4 of 43

3515 BROADWAY AVE

SUMMARY STATEMENT OF DEFICIENCIES