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Based on record reviews and administrative interviews, it was determined the hospital does not have an effective governing body legally responsible for the conduct of the hospital as an institution as it relates to Condition of Participation at A0115 Patient Rights and A0263 Quality Assurance Performance Improvement and Standards at A0129 Patient Rights, A0146 Patient Rights, A0395 Nursing Services, A0404 Nursing Services, A0490 Nursing Services, A0505 Pharmacy, and A1125 Rehab. Services. The governing body is responsible for the conduct of the hospital as an institution.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

1. Failure to honor "Patient Rights" related to choices and confidentiality of clinical records.

2. "Quality Assurance Performance Improvement" related to lack of program and integration into an interdisciplinary meeting.

3. "Nursing Services" related to lack of communications, transcription errors, medication standards not being met, and an unidentified, unlabeled syringe.

4. "Pharmacy" related to outdated medications not being recognized.

5. "Rehabilitation Services" related to lack of a Director.

Based on review of facility community meeting minutes, observations, and interviews, the facility failed to protect and promote patient rights as they pertain to choices of recreation, snacks, and confidentiality of clinical information as it relates to this Condition of Participation and Standards at A0129 and A0146.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

A review of patient meeting minutes, observations, and interviews, the facility failed to ensure that patient were free to exercise their rights pertaining to choice of recreation activities and snacks. Refer to A0129 for additional information.

Observations and interviews, the facility failed to ensure the confidentiality of the clinical records for 9 random sampled patients. Refer to A0146 for additional information.

Based on review of patient meeting minutes, observations and interviews, the facility failed to ensure patients were free to exercise their rights as pertaining to choice of recreation activities and snacks.

The findings include:

1. Review of facility Community Meetings throughout the day on 04/13/10 found some of the following requests from the patients in attendance.

Meeting of 01/16/10: "Heat pool (turn on earlier), more lifeguard hours. Yoga, handball, tennis, shuffleboard, badminton, basket ball. Snacks available to 8:30 p.m."

Meeting of 02/15/10: "More activities on weekends, games, access to act material (basketball, shuffle board, hardball), more pool time, equipment (ping pong balls, paddles. More variety at night snacks."

Meeting of 03/01/10: "More exercise & activities, more pool time (tired of excuses - too much chlorine - too cold, repairs) tennis, basket ball, handball available, yoga, ty-bo classes."

Meeting of 03/22/10: "Life guard hours--want more pool time on weekends, 2nd. guard for more pool time; vending machines, change machine."

Meeting of 04/05/10: "More pool time, towels by pool."

During an interview with the Director of Human Resources on 04/12/10 she/he stated, "The Recreation Therapist was a part time employee that worked 3 to 4 hours a week. The pool is open 3 times a week. The hours the pool is available to the patients is not posted."

Review of the Recreation Therapist's time card at this time revealed the following information.
The therapist had "clocked in on: Clocked out:
Monday 3/01/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/03/10 at 7:00 a.m. 10:00 a.m.
Thursday 3/04/10 at 7:00 a.m. 9:30 a.m.

Sunday 3/07/10 at 13:00 15:00
Monday 3/08/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/10/10 at 7:15 a.m. 9:00 a.m.

Sunday 3/14/10 at 13:00 p.m. 15:00 p.m.
Monday 3/15/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/17/10 at 7:00 a.m. 9:00 a.m.

Sunday 3/21/10 at 13:00 15:00
Monday 3/22/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/24/10 at 7:00 a.m. 10:00 a.m.
Thursday 3/25/10 at 7:00 a.m. 10:00 a.m.

Sunday 3/28/10 at 13:00 15:00

Tuesday 3/30/10 at 5:30 a.m. 6:30 a.m.

Sunday 4/04/10 at 13:00 15:00

Tuesday 4/06/10 at 7:00 a.m. 10:00 a.m.

The Director of Human Services stated at this time and date, "a position for an additional or full time recreational therapist had not been posted."

During the Quality Assessment and Performance Improvement program (QAPI) meeting held on 04/14/10 between 11:00 a.m. and 1:00 p.m. the Clinical Director responsible for the Recreation Therapist confirmed this information.

2. Review of the clinical record for Patient #18 on 4/14/10 reveals nursing documentation in the patient care notes dated 4/11/10 on the evening shift "patient was walking around the parking lot with a female patient from the 100 wing. MHT (Mental Health Tech) advised both patients that they couldn't be walking together outside and that there needed to be staff outside with them. The female patient was tearful and was upset about what had happened. She in fact did look at the handbook and could not find anything about not being able to walk around building. This writer did look at the rules; two small sentences no running in parking lot due to uneven pavement, only walking aloud. This patient became upset and started cursing because tech made patient cry."

Review of the facility's "Client Handbook" reveals in section four titled rules and guidelines under letter "k" No running in parking lot due to uneven pavement, only walking is permitted. Interview with a MHT on 4/14/10 at 10:32 a.m. regarding the rules of being outside revealed, "They don't like the patients outside where they can't be monitored." MHT was unaware that there is no rule in the client handbook prohibiting the patients from being outside.

3. Observations of the vending machines available to patients during the three days of the survey found a sign posted in the area with the following information:
"Hours of Operation Sunday thru Saturday 7:00 a.m. to 11:00 a.m.; 12:00 p.m. to 2:30 p.m.; 3:30 p.m. to 6:00 p.m. Change will be available between the hours of: 9:00 a.m. to 10:00 a.m. and 3:00 p.m. to 4:00 p.m. at the reception desk. Please make sure you have a tech with you before proceeding to the front. Thank You Administration."

To use the available vending machines the patients must have the correct change and adhere to strict available hours. When not available, the machine area is locked.

Based on observations and interviews, the facility failed to ensure the confidentiality of the clinical records for 9 random sampled patients.

The findings include:

During the initial tour of the facility on 4/12/10 at 9:40 a.m. an observation was made in the 100 hall of a room designated as the "Activity Room." This room contained a table near the center with chairs around it. A patient was noted to be sitting on a chair at this table. Closer observation of this area noted numerous clipboards on the table with documents attached. The clipboards (9 in total) contained two pieces of paper. The top sheet contained, in part, the patient name, and current medications. The second page, which was a yellow sheet, contained "Progress Notes." At the time of the initial observation, no staff member was in the room.

Interview at this time with the Mental Health Tech revealed he was doing vital signs for these patients who were "detox only patients." He further stated the clipboards were there so he would have the information handy when he saw the patient.

Based on an interview with the Medical Director, Quality Director, Infection Control Nurse, observations, and review of facility Quality Assurance Performance Improvement program, it has been determined the facility failed to ensure the Quality Assessment Performance Improvement efforts were interdisciplinary. Failure to demonstrate the hospital's governing body as being responsible and accountable for ensuring on-going specific Quality Assurance Performance Improvement program requirements are being met. Failure to implement a Quality Assessment Performance Improvement program to ensure accountability and addressed priorities for improved quality of care by all departments of the hospital.

The findings include:

The facility provided quarterly minutes dated 3/26/09, 6/23/09, 10/5/09, 11/12/09, and 1/7/10 for the Quality Assessment Performance Improvement (QAPI) program. The Infection Control (IC) Nurse was not listed as a member in attendance at any of the meetings. The infection control report is listed as deferred in the 3/26/09, 6/23/09, and 10/5/09 meeting minutes. The 11/12/09 minutes reflect the second quarter infection control report was reviewed. The 1/7/10 minutes reflect the third quarter infection control report was reviewed. The Infection Control (IC) reports were not presented as attachments to the minutes. No tracking and trending for Performance Improvements (PI) projects was identified. While in attendance at the facility QAPI meeting on 4/14/10 at 11:05 a.m., the Medical Director acknowledged, "Infection control data needs to be reported in a timely manner."

During an interview with the Quality Director and the Infection Control Nurse on 4/14/10 at 3:45 p.m., the Quality Director stated the Infection Control Nurse had not been attending the QAPI meetings and the Infection Control Nurse just began attending meetings in November 2009. She stated, "It was an oversight on our part."

During an interview on 04/13/2010 at approximately 10:30 a.m. with the Clinical Director responsible for Discharge Planning and the Recreation Therapist he/she stated they were not a member of the Quality Assessment and Performance Improvement program committee (QAPI).

During a facility QAPI committee meeting held from 11:00 a.m. to 1:00 p.m. on 04/14/10 both the facility Corporate Medical Director and the Director of Quality Assurance confirmed that Discharge Planning, Recreation and Rehabilitation Departments had not been included in the QAPI program.

On 4/14/10 at 11:00 a.m. during the Quality Assurance Performance Improvement Meeting the Director of Quality Assurance confirmed the Pharmacist had not been part of these meetings and that these meetings had not been "totally interdisciplinary."

Based on clinical record reviews, interviews, and reviews of policies and procedures, it was determined the hospital does not have an effective organized Nursing Department that provides 24-hour services to maintain the health, safety and well-being of the patients it serves as it relates to the Condition of Participation and Standard A0395 and A0404.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

1. Observation, interview and clinical record review, the facility failed to ensure nursing care for each patient is supervised by a registered nurse for 4 (Patients #16, #17, #18, and #20) of 20 sampled patients. This is evidenced by the clinical records not containing the results of ordered labs for 4 (Patients #16, #17, #18, and #20), no documentation of the physicians ordering labs being contacted regarding the lab results for 4 (Patients #16, #17, #18, and #20) and labs not obtained as ordered by the physician for 2 (Patients #16, and #20) .

2. Observation, interview and clinical record review, the facility failed to prepare and administer drugs and biologicals in accordance with Federal and State laws, the orders of the practitioner responsible for the patients care for 3 (Patients #15, #16, and #17) of 20 sampled patients and under acceptable standards of practice.

Based on observation, interview and clinical record review, the facility failed to ensure nursing care for each patient is supervised by a registered nurse for 4 (Patients #16, #17, #18, and #20) of 20 sampled patients. This is evidenced by the clinical records not containing the results of ordered labs for 4 (Patients #16, #17, #18, and #20), no documentation of the physicians ordering labs being contacted regarding the lab results for 4 (Patients #16, #17, #18, and #20), and labs not obtained as ordered by the physician for 2 (Patients #16, and #20).

The findings include:

1. Review of the clinical record on 4/13/10 for Patient #16 revealed an order written on 4/1/10 to obtain a lithium level. On 4/6/10 at 6:50 p.m. the physician writes an order "please obtain Lithium Level results."
Lithium is used to treat and prevent episodes of mania (frenzied, abnormally excited mood) in people with bipolar disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Lithium is in a class of medications called antimanic agents. It works by decreasing abnormal activity in the brain. Take lithium exactly as directed. (Source - "MedPlus" online medication information)

Again on 4/10/10 at 10:30 a.m. the same physician writes an order to "Please obtain Lithium level results which were ordered 4/1/10" he also increased the patients Lithium dose and ordered another Lithium level. Interview with the registered nurse responsible for Patient #16 on 4/13/10 at 11:20 a.m. confirmed the Lithium results from 4/1/10 were still not in the clinical record. She obtained the results for 4/1/10 from the computer which revealed an abnormally low level at 0.40mEq/L (normal is 0.5 - 1.5 mEq/L). She was unable to locate any Lithium results for 4/10/10 as ordered. She also confirmed there were no progress notes regarding notification of the results to the physician. The RN confirmed it took the facility 12 days and surveyor intervention to obtain Lithium results and report abnormal results to the patient's physician.

2. Review of the clinical record for Patient #17 revealed the patient was admitted 4/1/10 with orders to obtain Urinalysis, CBC with differential, CMP, RPR, and liver profile. Further review of the clinical record revealed an HIV result dated 4/8/10 the urinalysis results obtained on 4/2/10 but failed to contain the results for the remaining ordered labs. On 4/7/10 the physician writes an order to "send to outpatient to draw blood, not Friday - Tomorrow!! Please." The next order is a telephone order dated 4/8/10 11:00 a.m. "For tomorrow April 9/10 draw CBC w/diff, HIV test, and Hepatitis Profile." The following order dated 4/11/10 11:35 a.m. "RTO (results to office) when labs available" written by the attending physician.

Interview on 4/13/10 11:43 a.m. with the registered nurse confirms Hematology and Serology results were not in the clinical record. She obtained the lab results from the computer which reveal the HIV test was completed twice on Patient #17, the first on 4/8/10 by DSI Laboratories and the second on 4/9/10 by Finlay Clinical Laboratory. The RN confirmed the facility took 8 days with surveyor intervention to obtain labs and also confirmed the physician as of the 12th day is unaware of lab results.

3. Review of the clinical record on 4/13/10 for Patient #18 reveal the patient was admitted on 4/6/10. The admission orders on 4/6/10 included to obtain the following labs; Urinalysis, CBC with Differential, CMP, RPR, and liver profile. On 4/7/10 at 10:45 a.m. the attending physician writes to RTO with lab results. Further review of the clinical record for Patient #18 reveal the section with the tab labeled Labs to be empty and lacking the results of the previously ordered labs.

Interview on 4/13/10 at 2:43 p.m. with a unit registered nurse confirmed the lab results were not in the clinical record. She obtained the results from the computer. She confirmed there is no evidence in the clinical record that the physician was notified of the abnormal Neutrophil or Lymphocyte counts or that the patient was positive for benzodiazepines, cocaine and opiates in the urine drug analysis. The RN confirmed it has taken 7 days and surveyor intervention to obtain the ordered lab results for Patient #18.

4. Review of the clinical record for Patient #20 reveals the patient was admitted to the facility on 4/2/10 with the diagnosis of but not limited to GERD, Arthritis, Neuropathy and HIV without medication tx due to liver problems. The admission orders dated 4/2/10 at 8:00 p.m. included the following labs; Urinalysis with drug screen, CBC with Differential, CMP, RPR, and liver function tests. Another order followed on 4/3/10 to add CD4 count with the labs and to return 4/9/10 to review all labs. On 4/8/10, patient was experiencing urinary frequency and the physician ordered another Urinalysis but included a culture and sensitivity, and to return to office with urine reports in one week. Further review of the clinical record on 4/14/10 revealed no lab results in the record. On 4/14/10 at 10:12 a.m. the unit registered nurse confirmed there were no labs in the clinical record. She went to the computer and discovered only Urinalysis with Bacteriology dated 4/9/10 along with a CBC, Chemistry, RPR, liver function tests also dated 4/9/10, all dated 7 days after they were ordered. There was no evidence a CD4 count was added. The RN was unable to print the labs and called the lab to fax the results to the facility. The RN submitted the results to the surveyor including a lab dated 4/14/10 for a CD4 pending. The RN confirmed on 4/14/10 at 2:35 p.m. the physician was not notified of the lab results. Review of the lab results revealed a low WBC of 4.5 K/uL, low Neutrophil count of 36.50L.

Interview with the Director of Nursing on 4/13/10 at 11:20 a.m. reveal labs are drawn on Mondays, Wednesdays, and Fridays. She states the results are reported by the lab in the computer and it is the nurses' responsibility to obtain the results from the computer and file in the clinical records. She states abnormal labs are called to the ordering physician by phone and documented in the progress notes.

Review of the facility policy and procedure for laboratory services (NUR-7:021) reveal lab results will be transmitted at intervals daily to the Willough on the printer provided by the lab. The coordination of reviewing lab reports is as follows:
A) The report is received in the eating disorders nursing station.
B) The nurse dates and initials the report and places it in the "to be filed" box on the nurses' station.
C) A copy of the report is placed in the lab section of the patient record.
D) The copy of the requisition is sent to financial services to maintain patient accounts.

The policy goes on to state urgently needed lab information and critical lab values will be communicated by telephone from the lab to a nurse in the respective program unit. The nurse will log it into the critical lab book and immediately communicate this information to the attending physician or physician on call or the Medical Department so that it has an appropriate impact on patient care. The above is also documented in the patient progress notes.

On 4/13/10 at 11:25 a.m. nurses on the 200 unit were unable to locate a "critical lab book."

Based on observation, interview, and clinical record review, the facility failed to prepare and administer drugs and biologicals in accordance with Federal and State laws, the orders of the practitioner responsible for the patients care for 3 (Patients #15, #16, and #17) of 20 sampled patients and under acceptable standards of practice.

Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner; "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirmed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist.

The findings include:

1. Observation of the medication pass on the 200 hall on 4/12/10 at 9:42 a.m. reveals a wooden tray on top of the medication cart. The tray contained many clear plastic pudding size cups with patient names containing single unit doses of packaged medications. Some of the clear plastic cups were observed to contain paper souffle cups containing white or yellow unidentifiable tablets. Some of the plastic cups were timed 10 a.m. and some timed 12 noon.

Interview with the nurse administering the medications reveal the practice of the facility is to pre-pour the medications prior to the medication times. She then compares the medications to the medication administration record when administering the medications to the patients. She stated she poured her 10:00 a.m. meds and 12:00 noon meds. When asked about the medications in the souffle cups the nurse stated the tablets were Tylenols or Vitamins that were from the stock meds in the med prep room stating there were no narcotics in the souffle cups. When asked where the narcotics were kept she responded, "in the med prep room."

Observed also on the tray was a plastic cup with 2 exposed q-tips with a clear salve on them and a plastic cup with a pink liquid containing a tape across the top labeled Hibiclens. The nurse was observed at 9:51 a.m. to go into the med prep room without the use of a key leaving the med cart unattended in the presence of the surveyor with a patient at the window and the door to the nurses' station unlocked.

Observation of the medication pass on the 200 unit on 4/13/10 at 9:16 a.m. revealed unidentifiable tablets in souffle cups on top of the medication cart. Interview with the registered nurse administering the medications stated she labeled all the souffle cups with the patient name and the name of the medication contained in the souffle cup. She picked up one souffle cup that was identified only with the patient name and the nurse was unable to identify the white tablet contained in the cup.

Interview with the Director of Nursing on 4/13/10 at 10:35 a.m. she states that she is of the understanding the medication pass was correctly being done as per previous surveys. She explained the nurses pre-pour the stock medications which are kept in the medication room and nurses had to come back to the med prep room to remove any secured medications like narcotics, as they are to be administered to the patients. She confirmed the medication room was to remain locked at all times.

Review of the facility policy on Medication Administration (NUR-7:011) reveals under administration of oral medications, "After checking with the physicians order, read the label three times while preparing the drug, maintaining unit doses integrity until the patient is to receive all medications, keeping the drug in sight at all times." The policy also states, "No medication is to be double poured or signed off prior to the patient receiving their medication."

2. Review of the clinical record on 4/13/10 for Patient #15 revealed the medication Suboxone 8 mg was last renewed on 4/8/10 at 6:00 p.m. and expired on 4/11/10 at 12:00 p.m. Review of the Medication Administration Record for Patient #15 reveals the patient still receiving the Suboxone on 4/11/10 at 6:00 p.m., 4/12/10 at 6:00 a.m., 12:00 p.m., 6:00 p.m., and on 4/13/10 at 6:00 a.m.

Interview with the registered nurse on 4/13/10 at 1:35 p.m. stated she just received a renewal telephone order for the medication and confirmed the patient had received 5 doses without a physicians order.

Review of the Nursing 2010 Drug Handbook reveals Suboxone is an Opioid Agonist and is a class III medication.

3. Review of the Medication Administration Record (MAR) for Patient #16 reveals medication entry for Trazodone HCL 100 mg 1 tab at bedtime by mouth with instructions to take with 50 mg total of 150 mg every bedtime. The 100 mg Trazodone signed off every night 4/3/10 thru 4/12/10. The MAR also reveals another entry for Trazodone HCL 50 mg tabs 1 tab at bedtime as needed. Off to the side there is an additional handwritten instruction, "150 mg =3 Tabs." This dose of Trazodone was signed off on 4/5/10, 4/9/10 thru 4/12/10. The MARs indicate the patient has received Trazodone 250 mg on 5 of the previous 10 nights. Review of the physician's orders dated 3/27/10 reveal the last order for Trazodone to "discontinue Trazodone as written, Trazodone 150 mg po at HS PRN for insomnia." Review of the medication drawer containing the unit dose medications for Patient #16 revealed 2 ziplock bags the first labeled Trazodone 100 mg (take with 50 mg = 150 mg) and the second bag labeled Trazodone 50 mg.

Registered nurse on the unit on 4/13/10 at 12:34 p.m. was unable to determine how much Trazodone the patient has received. She confirmed according to the MAR the patient could have received a larger amount of the Trazodone than ordered by the physician.

The Director of Nursing confirmed on 4/13/10 at 2:46 p.m. that there is a transcription error for the order of Trazodone on 3/27/10.

4. Review of the clinical record on 4/13/10 for Patient #17 revealed the medication Suboxone 4 mg was last renewed on 4/8/10 at 12:00 p.m. and expired on 4/11/10 at 6:00 a.m. Review of the Medication Administration Record reveals the patient received doses on 4/11/10 at 12:00 p.m., 6:00 p.m., 4/12/10 at 6:00 a.m., 12:00 p.m. and 6:00 p.m. and on 4/13/10 at 6:00 a.m.

Interview with the Registered Nurse on 4/13/10 at 1:35 p.m. stated she just received a renewal telephone order for the medication and confirmed the patient had received 6 doses without a physicians order.

Review of the Nursing 2010 Drug Handbook reveals Suboxone is an Opioid Agonist and is a class III medication.

During an interview with the Director of Nursing and the Medical Director on 4/15/10, it was revealed the facility does not have medication carts for the units to utilize during medication pass. The medication cart that is available on the 200 hall is unserviceable and a hazard for the nurses to use. The process the nurses are using for medication prep is the result of the lack of a useable medication cart to store and secure individual patient medications.

5. On 4/12/2020 at 10:50 a.m. during review of the medication room in the 100 wing, a 3 milliliter syringe was observed on top of the medication cart which contained 1 milliliter of drawn red solution. Surveyor asked the nurse administering medications about the syringe and its contents but she was unable to show where the medication had been drawn from and for who she had prepared it for. In front of the surveyor she then wrote on the back of the syringe package "B-12." The Director of Pharmacy who was present during the finding stated the medication should have either been labeled appropriately or discarded and then drawn up again at the time of administration.

6. On 4/12/2010 at 10:54 a.m. during review of the medication room in the 100 wing, 2 ampoules of Cogentin 2 mg/ml were found that had expired on March 2010. Director of Pharmacy present at the time removed the expired ampoules.

Based on interviews and review of QAPI minutes, the facility failed to meet the Conditions of Participation as demonstrated by; failure to have a Rehabilitation Department that is organized and staffed to ensure the health and safety of patients. The Rehabilitation Department does not have a designated director. Failure to include the department in the hospital-wide QAPI program.

The findings include:

1. During interviews and reviews of the organization chart, it was revealed the facility failed to have a Director of Rehabilitation services responsible to oversee the services and staff providing physical therapy to patients.

2. During the Quality Assurance and Performance Improvement meeting held on 4/14/10 at about 3:30 p.m. it was revealed the Rehabilitation Department was not a part of the committee and does not attend, nor report quality issues/projects.

Based on interviews and review of the organization chart, the facility failed to have a Director of Rehabilitation services responsible to oversee the services and staff providing physical therapy to patients.

The findings include:

1. During review of the facility organizational chart on 04/13/2010 at 9:00 a.m. no Director of Rehabilitation services was documented. A job description for this title was requested from the Chief Operations Officer. One was not provided during the survey. The facility had a contract with a rehabilitation company effective 12/07/2009.

During an interview with one of the two contracted physical therapist on 04/14/2010 at 2:45 p.m. she/he stated they did not know who in the facility was responsible for the therapists and that there was no facility Rehabilitation Director.

During an interview with the Corporate Medical Director on 04/14/2010 at 4:30 p.m. she/he stated the facility "had no policies and procedures for the Rehabilitation Department, no Director of Rehabilitation services or job descriptions for a director or physical therapists."

Based on patient and staff interview the facility failed to arrange and provide consistent therapeutic activities for patients of the facility.

The findings include:

During confidential interviews on 4/13/10 a patient stated she/he would like to use the pool and did not understand why it was closed. The patient stated, in the past there were other outdoor activities available such as basketball. The patient stated that all they had now was the ping pong table.

A confidential interview with another patient, on 4/13/10, revealed that the patient would like to get out for a walk more often. The patient stated, "It was nice getting out; a staff took me out to walk in the parking lot last weekend."

Review of facility Community Meetings throughout out the day on 04/13/2010 found some of the following requests from the patients in attendance.

Meeting of 01/16/10: "Heat pool (turn on earlier), more lifeguard hours."

Meeting of 02/15/10: "More activities on weekends, games, access to act material (basketball, shuffle board, hardball), more pool time, equipment (ping pong balls, paddles). More variety at night snacks."

Meeting of 03/01/10: "More exercise & activities, more pool time (tired of excuses - too much chlorine - too cold, repair) tennis, basket ball, handball available, yoga, ty-bo classes."

Meeting of 03/22/10: "Life guard hours--want more pool time on weekends; vending machines, change machine."

Meeting of 04/05/10: "More pool time, towels by pool."

During an interview with the Director of Human Resources on 04/12/2010, she/he stated, "The Recreation Therapist was a part time employee that worked 3 to 4 hours a week. The pool is open 3 times a week. The hours the pool is available to the patients is not posted."

Review of the Recreation Therapist's time card at this time revealed the following information.
The therapist had "clocked in on: Clocked out:
Monday 3/01/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/03/10 at 7:00 a.m. 10:00 a.m.
Thursday 3/04/10 at 7:00 a.m. 9:30 a.m.

Sunday 3/07/10 at 13:00 15:00
Monday 3/08/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/10/10 at 7:15 a.m. 9:00 a.m.

Sunday 3/14/10 at 13:00 p.m. 15:00 p.m.
Monday 3/15/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/17/10 at 7:00 a.m. 9:00 a.m.

Sunday 3/21/10 at 13:00 15:00
Monday 3/22/10 at 7:00 a.m. 10:00 a.m.

Wednesday 3/24/10 at 7:00 a.m. 10:00 a.m.
Thursday 3/25/10 at 7:00 a.m. 10:00 a.m.

Sunday 3/28/10 at 13:00 15:00

Tuesday 3/30/10 at 5:30 a.m. 6:30 a.m.

Sunday 4/04/10 at 13:00 15:00

Tuesday 4/06/10 at 7:00 a.m. 10:00 a.m."

The Director of Human Services stated at this time and date "A position for an additional or full time Recreational Therapist had not been posted."

During the Quality Assessment and Performance Improvement program (QAPI) meeting held on 04/14/10 between 11:00 a.m. and 1:00 p.m., the Clinical Director responsible for the Recreation Therapist confirmed this information.