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Based on medical record review, document review, and interview, the facility failed to provide psychosocial assessments that met professional social work standards for seven (7) of eight (8) sample patients (A1, A2, A3, A4, A5, A7, and A8). These assessments failed to include conclusions and recommendations that described anticipated social work roles for individualized treatment and discharge planning. The Psychosocial Assessment listed descriptive information about the patient rather than an assessment of the information obtained during the interview. In addition, the recommendation/conclusion section of the assessment format frequently listed patient goals or generic rather than individualized social work interventions. This deficiency results in a lack of professional social work treatment services necessary to meet individualized patient needs.

Findings Include:

A. Medical Records

1. Patient A1's Psychosocial Assessment, dated 11/1/17, listed for Recommendations and Conclusions the following: "pt [patient] will demonstrate improved [sic] in mood, thinking and behavior" and "Therapist will design tx [treatment] plan and facilitate group and family therapy."

2. Patient A2's Psychosocial Assessment, dated 11/3/17, listed for Recommendations and Conclusions the following: "Pt will have a reduction in depression and will demonstrate the absence of suicidal thoughts" and "Therapist will facilitate D/C [discharge planning] and will arrange after care for Pt."

3. Patient A3's Psychosocial Assessment, dated 11/2/17, listed for Recommendations and Conclusions the following: "Pt will demonstrate the absence of SI [suicidal ideation] prior to D/C. Pt will participate in group session" and "Therapist will facilitate D/C planning and will arrange follow up care for pt."

4. Patient A4's Psychosocial Assessment, dated 10/20/17, listed for Recommendations and Conclusions the following: "Pt will attend group daily and will demonstrate the absence of agitation prior to D/C. Pt will follow Tx [treatment] plan" and "Therapist will offer group daily and will facilitate D/C planning and will arrange follow up care."

5. Patient A5's Psychosocial Assessment, dated 10/6/17 and updated 11/1/17, listed for Recommendations and Conclusions the following: (10/6/17) "the history will need to be completed once the patient is more cooperative. [S/he] was medicated early today" and (11/1/17) "Will facilitate group and discharge planning."

6. Patient A7's Psychosocial Assessment, dated 11/1/17, listed for Recommendations and Conclusions the following: "Pt will be compliant with tx, will learn DBT skills, will have absence of SI and a plan for safety after D/C and facilitate group therapy daily to allow Pt the opportunity to process difficult emotions and learn healthy coping skills."

7. Patient A8's Psychosocial Assessment, dated 11/3/17, listed for Recommendations and Conclusions the following: "Recent unwanted promotion at work recent breakup" and "Facilitate group therapy daily to allow Pt the opportunity to process difficult emotions and learn healthy coping skills."

B. Document Review

Review of Psychosocial Assessment, revised date 2/2017, revealed that there was no requirement in the body of the policy that required the documentation of conclusions and recommendations based on the information obtained from the assessment.

C. Interviews

1. In an interview on 11/7/17 at 9:00 a.m., the Director of Clinical Services concurred that current Psychosocial Assessments did not contain Assessment and Conclusions based on the information available.

2. In an interview on 11/8/17 at 9:45 a.m., the Director of Clinical Services concurred that the existing Psychosocial Assessment policy fails to require the documentation of conclusions based on assessment information obtained.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that include patient-related goals stated in measurable terms for three (3) of eight (8) active sample patients (A1, A2, and A3). In addition, the goals were nearly identical for all three patients. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient behaviors.

Findings Include:

A. Record Review

1. Patient A1 was admitted on 10/31/17. The Master Treatment Plan (MTP) dated 11/2/17 for the problem, "Depression SI (Suicidal Ideation)," documented the short-term goal of, "[Patient] will explore underlying issues that exacerbate depression and suicidal ideation by implementing cognitive reframing and mindfulness techniques to improve mood, thinking, and behavior as evidence by self-report and staff observation."

2. Patient A2 was admitted on 11/2/17. The MTP dated 11/3/17 for the problem, "Depression SI," documented the short-term goal of, "[Patient] will identify the underlying issues that exacerbate depression and implement mindfulness strategies and techniques to improve mood daily as evidenced by self-report and staff observation."

3. Patient A3 was admitted on 11/2/17. The MTP dated 1/3/17 for the problem, "Depression SI," documented the short-term goal of, "[Patient] will identify the underlying issues that exacerbated depression and implement mindfulness strategies and techniques to improve mood daily as evidenced by self-report and staff observation."

B. Policy Review

The hospital policy, "Interdisciplinary Treatment Plan" reviewed 2/20/17 stated, "Short-term goals are stated as stepping stones to the long-term goals and are stated in specific behavioral, observable terms."

C. Interview

During an interview on 11/7/17 at 12:15 p.m., the Director of Clinical Services agreed that the goals for Patients A1, A2, and A3 were not measurable and were almost identical in wording.

Based on record review and interview, the facility failed to develop MTPs that included individualized interventions to address specific treatment needs for seven (7) of eight (8) sampled patients (A1, A2, A3, A5, A6, A7, and A8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient-specific interventions. This deficiency results in a lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment.

Findings Include:

A. Medical Records

1. Patient A1's MTP, dated 11/2/17, listed for the short-term goal (STG), "[Patient] will explore underlying issues that exacerbate depression and suicidal ideation by implementing cognitive reframing and mindfulness techniques to improve mood, thinking, and behavior as evidence by self-report and staff observation." The interventions listed were "Administer, Educate and Monitor [medication]" for Nursing, and no interventions were listed for the psychiatrist.

2. Patient A2's MTP, dated 11/3/17, listed for the STG, "[Patient] will identify the underlying issues that exacerbate depression and implement mindfulness strategies and techniques to improved mood daily as evidenced by self-report and staff observation." The interventions listed were "Administer, Educate, Assess and Monitor [medication]" for Nursing. There were no interventions listed for the psychiatrist.

3. Patient A3's MTP, dated 11/3/17, listed for the STG, "[Patient] will identify the underlying issues that exacerbated depression and implement mindfulness strategies and techniques to improve mood daily as evidenced by self-report and staff observation." The interventions listed were Administer, Educate, Assess and Monitor [medications] for Nursing. There were no interventions listed for the Psychiatrist.

4. Patient A5's MTP, dated 11/5/17, listed for the STG, "[Patient] will attend process group daily to process his use of distress tolerance skills in order to more efficiency control [his/her] behavior and emotions." The interventions listed were "order meds" for the psychiatrist, "administer medications" for the nurse, and "process group for 60 minutes session 7 days a week" for the Social Worker.

5. Patient A6's MTP, dated 11/4/17, listed for the short-term goal, "[Patient] will begin to identify and address moods and symptoms of impulsivity i.e. the events that led to depressed mood." The only intervention on the treatment plan was Nursing, "Administer, Educate, Assess, and Monitor the following [nothing listed]." There were no interventions listed for the psychiatrist and social work on the treatment plan.

6. Patient A7's MTP, dated 11/3/17, listed for the short-term goal, "[Patient] will complete a crisis safety plan including three ways to cope in a healthy manner with difficulty obtaining medications. Will discuss with therapist 2 days prior to discharge." The interventions listed were "Order, Monitor meds for the psychiatrist, "Administer, Assess and Monitor [medications]" for the Nurse, and "Process Group 60 minutes a session 7 day per week" for the Social Worker.

7. Patient A8's MTP, dated 11/5/17, listed for the short-term goal, "[Patient] will complete a safety crisis plan including 3 ways to cope in a healthy manner with relationship or occupations stressors." The interventions listed were "Order" medications for the psychiatrist, "Administer, Educate, Assess, and Monitor [medications]" for the Nurse, and "Process group for 60-minute sessions 7 days per week" for the Social Worker.

C. Interviews

1. In an interview on 11/7/17 at 3:30 p.m., the Chief Nursing Officer concurred that nursing interventions were not individualized and were generic nursing functions.

2. In an interview on 11/8/17 at 9:00 a.m., the Director of Clinical Services concurred that treatment interventions on the treatment plans were not individualized.

Based on medical record review, document review, and interview, the facility failed to ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge in 16 of 19 discharge records reviewed (D1, D2, D3, D6, D7, D8, D9, D10, D11, D12, D13, D14, D15, D16, D17, and D18). This deficiency results in a failure to communicate, in a timely manner, final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers.

Findings Include:

A. Medical Record Review

Nineteen (19) medical records were reviewed for timelines of completion of the discharge summaries. The record review indicated that 16 of the discharge summaries were not completed due to the lack of a physician's review and signature within the facility's time frames.

B. Document Review

Medical Staff Rules and Regulations (Revised 8/2017) page 17 stated, "The inpatient Discharge Summary shall be entered into the patient's medical record within 30 days after discharge, and shall be documented and signed by the attending physician."

C. Interview

1. In an interview on 11/7/17 at 9:30 a.m., the Chief Medical Officer acknowledged he was aware of the difficulties with medical records.

2. In an interview on 11/7/17 at 2:15 p.m., the Health Information Officer confirmed that medical records were not considered complete until they had been reviewed and signed by the physician. In addition, she indicated that discharge summaries were not sent to outpatient providers until they were signed by the physician.

3. In an interview on 11/7/17 at 3:00 p.m., the Chief Executive Officer acknowledged that he was aware of the problem with the timeliness of medical record completion.

Based on document review and interview, the medical director failed to ensure:

I. That physician behaviors were in keeping with respectful speech and conduct when interacting with patients, staff, or surveyors. Leadership at the facility (Chief Medical Officer/CEO/Risk Manager) all acknowledged that there had been multiple complaints from patients and staff regarding Physician 1 and Physician 2. Specifically, the complaints centered on these physicians' behaviors. This deficient practice diminishes the therapeutic relationship between the physician and patients, potentially impacting the quality of active treatment and psychiatric care.

Findings include:

A. Document Review

1. Review of the September 2017 Performance Improvement Report revealed that 11 grievances had been received for the quarter. Of those 11, eight (8) were grievances related to physician behavior or practice.

2. Review of the policy "Medical Staff Disruptive Behavior Policy" effective 4/2016, revealed specific guidelines for dealing with "conduct that has a potentially adverse impact on the Hospital's ability to provide quality patient care" and included behaviors such as: threatening, abusive language, intimidating, degrading and bullying. Although the policy specifically addressed how to classify and deal with disruptive behavior, review of the HR records revealed that the policy was not being followed for Physician 2. Physician 2 had a note by the CMO in his/her personnel record dated 9/22/17, the date of an incident with a Joint Commission surveyor, stating, "This is a serious incident and that [s/he] can expect a PIP (Performance Improvement Plan)." A PIP was never implemented.

B. Interview

In an interview on 11/8/17 at 10:00 a.m., the Chief Medical Officer stated that he was aware of the treatment plan deficiencies, discharge summary deficiencies, and problems with physician behavior.

II. That MTPs include patient-related goals stated in measurable terms for three (3) of eight (8) active sample patients (A1, A2, and A3). In addition, the goals were nearly identical for all three patients. This deficient practice hampers the ability of the treatment team to provide goal-directed treatment and to determine the effectiveness of interventions based on changes in patient behaviors. (Refer to B121).

III. The development of MTPs that included individualized interventions to address specific treatment needs for seven (7) of eight (8) sampled patients (A1, A2, A3, A5, A6, A7, and A8). Listed interventions were stated in vague terms and were routine generic discipline functions rather than individualized patient-specific interventions. This deficiency results in a lack of guidance to treatment staff in providing individualized, coordinated treatment in the least restrictive environment. (Refer to B122).

IV. That discharge summaries were dictated, transcribed and filed within 30 days of discharge in 16 of 19 discharge records reviewed (D1, D2, D3, D6, D7, D8, D9, D10, D11, D12, D13, D14, D15, D16, D17, and D18). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems, and discharge plan with outpatient providers. (Refer to B133)

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions addressed individualized patient needs. The interventions were instead generic nursing functions that were provided for seven (7) of eight (8) active sample patients (A1, A2, A3, A5, A6, A7, and A8). The nursing interventions for all these patients were to administer, assess and monitor medications. Failure to provide for the individualized nursing needs of patients potentially hinders the recovery of the patient and could increase the length of hospitalization.

Interview

In an interview on 11/7/17 at 3:30 p.m., the Chief Nursing Officer concurred that nursing interventions were not individualized and were generic nursing functions.