Letter from Christine Peterson to the Legislature regarding the second Immediate Jeopardy at Beatrice State Developmental Center

From: Christine Z Peterson

Sent: 04/20/2007 04:48 PM

To: State Senators

Subject: CMS Exit

This morning, federal surveyors for the Centers for Medicare and Medicaid

(CMS) held an exit conference at the Beatrice State Developmental Center .

The original CMS survey was conducted on September 29, 2006.  Since then, staff have worked hard to implement the corrective action plan that was required.  The following is a summary prepared by Larry Pezley, Acting Administrator, Beatrice State Developmental Center .

"AMAZING CHANGE"  Quote from the Lead CMS Surveyor

Beatrice State Developmental Center (BSDC) has been found 'IN COMPLIANCE' for 6 of the 8 Conditions of Participation by the CMS Survey Team.  This means that we brought 5 Conditions back into compliance during the past 6 months.  We are still Out of Compliance under conditions for Client Protections and Governing Body.  The 6 conditions found in compliance at BSDC included all the Regulation Tags for: 1) Facility Staffing, 2) Active Treatment, 3) Client Behavior and Facilty Practice, 4) Healthcare Services, 5) Physical Environment, and 6)  Dietetic Services. These Conditions include a total of 309 Regulation Tags that were all found to be in compliance for BSDC.

The surveyors have seen an "amazing change" throughout our facility since September of 2006.  They noted "tremendous progress" throughout the facility and indicated that as an organization, we are headed in the right direction. CMS stated that the attitudes and efforts of staff have been wonderful during their time on campus. They noted that every interaction they observed between the staff and clients was truly amazing.

However, on the last day of the CMS survey BSDC was cited to be in Immediate Jeopardy for the Condition for Client Protections which automatically included noncompliance for the condition for the Governing Body. This citation was not due to any one person, or team, or department failing.  There was no serious harm to anyone which usually triggers the Immediate Jeopardy finding.  The citation was made due to a system error in the areas of Client Protections and the investigation processes.  Work was already underway to improve this area and will continue to assure we correct the deficiency.(emphasis added, The Arc)

The corrective actions that have already begun include the work of the Incident Review Team which started on April 2. This Review Team completes daily reviews of all client incidents/injuries to ensure that protective actions are in place. We will also continue to correct the review processes for peer to peer injuries and injuries of unknown origin so that protections are in place for individuals during and after the investigation process.

We anticipate continued collaboration with CMS to complete this compliance process.

Christine Z. Peterson

Chief Administrative Officer

Nebraska Health and Human Services System