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Based on document review and interview, it could not be determined that all contracted services at the facility were provided in a safe and effective manner due to failure to evaluate through the quality assessment and performance improvement (QAPI) program for 6 of 47 contracted services (annual fire alarm system certification, continuous fire alarm monitoring, emergency generator service, emergency medical transfers, fire extinguishers and pest control services).

Findings include:

1. Review of the policy/procedure Quality Assessment and Performance Improvement Plan (approved 5-16) indicated the following: "The individual and aggregate review of services of care and utilization includes...E. Review of contracted services and regular internal services provided."

2. Review of 2019 QAPI committee meeting minutes lacked documentation indicating the contracted service providers for the fire alarm system certification, fire alarm monitoring, fire extinguishers, emergency generator service, emergency medical transfers and/or pest control services were being evaluated through the QAPI program.

3. During an interview on 12-18-19 at 1450 hours, the Director of Social Work A6 and the Director of Quality Assurance and Performance Improvement A7 confirmed the 2019 QAPI minutes lacked documentation indicating the six contracted services were currently being reviewed by the program and no other documentation was available.

Based on document review and interview, the facility failed to maintain its list of all contracted services, including the scope and nature of the services provided, for 47 of 47 contracted services.

Findings include:

1. Review of a list of 42 contracted services dated 12-16-19 provided by the Service Records Supervisor and Corporate Compliance Clerk A4 lacked documentation indicating the scope and nature of the indicated services and failed to indicate the adjacent acute care hospital services provided by agreement including emergency medical transfer and treatment, laboratory services and meal services, or a service provider for pest control and an emergency generator.

2. Review of facility documentation indicated the following: emergency medical treatment, laboratory services and meal services were provided by an adjacent acute care hospital, pest control was provided by CS46, emergency generator service was provided by CS47, and three (3) different services (annual fire alarm system certification, continuous fire alarm monitoring and fire extinguisher service) were being provided by CS27.

3. During an interview on 12-18-14 at 1450 hours, the Director of Social Work A6 and the Director of Quality Assurance and Performance Improvement A7 confirmed that the list of contracted services failed to indicate the scope and nature of the listed services and/or the indicated service providers and had not been maintained.

Based on document review and interview, the facility failed to maintain its policies and procedures for emergency medical care and treatment for one occurrence.

Findings include:

1. Review of the policy/procedure Patient Transfers to MGH (approved 5-19) indicated the following: "Purpose: To facilitate the orderly transfer process from the acute care psychiatric hospital to ...[the adjacent acute care medical hospital]...emergency services..." and lacked a process for assessment including any guidelines for conducting an immediate appraisal of patients by an on-site Registered Nurse or other Qualified Medical Provider to identify and determine when a patient requires an emergency transfer and/or help determining the appropriate means for transport to the adjacent Emergency Department.

2. During an interview on 12-18-19 at 1500 hours, the Director of Social Work A6 and the Director of Quality Assurance and Performance Improvement A7 confirmed the policy/procedure lacked the indicated provisions to enable an emergency responder to recognize when a patient needs a transfer.

Based on document review, the facility failed to follow their policy to ensure patient and/or/patient representative participation in the development, implementation and update reviews of the patient treatment/care plans for 5 of 30 patients. (Patients #5, 9, 19, 25 and 27).

Findings include:

1. Facility policy titled "Treatment Plan" last reviewed/revised 4/2018 indicated the following: "...PROCEDURE: Each client/patient will have a treatment plan that is the joint effort of the patient and treating staff incorporating the goals of the patient and focused of psychiatric symptom resolution, ensuring life safety and improved quality of life...The treatment plan will be discussed with the patient and a signature obtained..."

2. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 11/17/19 and was a current patient.
(B) The patient's treatment plan dated 11/17/19 was signed by the patient on 11/20/19. The patient treatment plans created/updated on 11/27/19, 11/28/19, 12/1/19, 12/2/19, 12/6/19, 12/8/19 12/14/19, 12/15/19, 12/16/19 and 12/17/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated and/or refused to participate in the treatment plan, therefore it could not be determined that the patient or patient's representative participated and/or refused to participate in the treatment plan reviews/updates.

3. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 10/20/19 and was discharged on 10/31/19.
(B) The patient's treatment plan dated 10/21/19 was signed by the patient on 10/21/19. The patient treatment plans created/updated on 10/27/19, 10/29/19 and 10/30/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated and/or refused to participate in the treatment plan, therefore it could not be determined that the patient or patient's representative participated and/or refused to participate in the treatment plan reviews/updates.

4. Review of patient #19's medical record indicated the following:
(A) The patient was admitted on 8/22/19 and was discharged on 9/4/19.
(B) The patient's treatment plan dated 8/22/19 was signed by the patient on 8/23/19. The patient treatment plans created/updated on 8/29/19, 8/30/19, 8/31/19, 9/1/19, 9/3/19 and 9/4/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated and/or refused to participate in the treatment plan, therefore it could not be determined that the patient or patient's representative participated and/or refused to participate in the treatment plan reviews/updates.

5. Review of patient #25's medical record indicated the following:
(A) The patient was admitted on 9/8/19 and was discharged on 9/11/19.
(B) The patient treatment plans created/updated on 9/8/19, 9/9/19 and 9/10/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated and/or refused to participate in the treatment plan, therefore it could not be determined that the patient or patient's representative participated and/or refused to participate in the treatment plan reviews/updates.

6. Review of patient #27's medical record indicated the following:
(A) The patient was admitted on 8/9/19 and was discharged on 8/19/19.
(B) The patient treatment plans created/updated on 8/11/19, 8/12/19, 8/14/19, 8/15/19, 8/17/19 and 8/18/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated and/or refused to participate in the treatment plan, therefore it could not be determined that the patient or patient's representative participated and/or refused to participate in the treatment plan reviews/updates.

7. During an interview with A13 (Community Support Program Team Lead) on 12/18/19 at 3:52 p.m., he/she verified the medical record documentation for Patients #5, 9, 19, 25 and 27.

Based on document review and interview, the facility failed to ensure abuse and harassment policy included patient protection from abuse and harassment and allegations of patient abuse or mistreatment at the facility were reported and investigated for one occurrence.

Findings include:

1. Review of the policy/procedure Patient Neglect, Abuse, and Exploitation (revised 6-19) indicated the following: "2. The supervisor will contact the Chief Executive Officer (CEO) or the Division Director who will direct the supervisor in how to proceed with the investigation of the allegations...4. Staff who are found to have abused, neglected, or exploited a client or clients, who are abusing, neglecting or exploiting a client or clients (sic), shall be subject to the Center's Disciplinary Procedure. Continued employment will not be guaranteed..." and lacked a provision ensuring that patients were protected from abuse during investigations of allegations.

2. During an interview on 12-18-19 at 1440 hours, the Director of Social Work A6 and the Director of Quality Assurance and Performance Improvement A7 confirmed the policy/procedure lacked the indicated provisions and no other documentation was available.

Based on document review and interview, the facility failed to follow their job description for Psychiatric Technicians by failing to ensure employees provided proof of cardiopulmonary resuscitation (CPR) training/certification or obtained CPR certification for 2 of 3 Psychiatric Technician personnel records reviewed. (N2 and N4)

Findings include:

1. Facility job description titled "JOB DESCRIPTION...Title: Psychiatric Technician I"...Department: Inpatient...III. Qualifications (Knowledge and Critical Skills): A. Professional: ...3. Has or be willing to obtain CPR certification..."

2. Review of employee N2's (Psychiatric Technician) personnel record indicated the following:
(A) The employee was hired on 12/27/18.
(B) The personnel file lacked documentation of CPR certification.

3. Review of employee N4's (Psychiatric Technician) personnel record indicated the following:
(A) The employee was hired on 6/13/18.
(B) The personnel file lacked documentation of CPR certification.

4. During an interview on 12/18/19 at 5:50 p.m. with A50 (Human Resource Specialist), he/she verified that N2 and N4's personnel files lacked documentation of a current CPR certification.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6, failed to provide 1 of 1 correct written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6, failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5., faiiled to provide 1 of 1 correct written policies in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2. and failed to ensure the hospital grade electrical receptacles in 13 of 13 patient sleeping rooms were tested after initial installation, replacement, or servicing of the device (see Tag 709).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
failed to provide 1 of 1 correct written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6, failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly and gauges on dry systems (5.2.4.2) shall be inspected weekly to ensure normal water or air pressure is being maintained. NFPA 25 13.3.2.1 states valves should be inspected weekly or valves secured locks or supervised (13.3.2.1.1) shall be permitted to be inspected monthly, faiiled to provide 1 of 1 correct written policies in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.6 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly, failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
and failed to ensure the hospital grade electrical receptacles in 13 of 13 patient sleeping rooms were tested after initial installation, replacement, or servicing of the device. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. Section 6.3.3.2 states Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces).

Findings include:

1. Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:09 a.m., an annual visual/functional fire alarm inspection conducted on 01/04/19 was provided but documentation regarding a visual semi-annual fire alarm system inspection conducted six months after the anunal fire alarm inspection was not provided. Based on interview at the time of record review, the Maintenance Tech II stated a visual semi-annual inspection of the fire-alarm system was not completed.

2. Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:29 a.m., the facility did not provide documentation of a fire watch policy for when the fire alarm system is out of order. Based on interview during the record review, the Manager of Plant Operations stated the facility does not have a written fire watch policy.

3. Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:29 a.m., no monthly inspection of the wet pipe sprinkler system's gauges and valves were available for review. During an interview at the time of record review, the Maintenance Tech II stated the inspection of gauges and valves were not recorded.

4. Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:29 a.m., the facility did not provide documentation of a fire watch policy for when the fire sprinkler system is out of order. Based on interview during the record review, the Manager of Plant Operations stated the facility does not have a written fire watch policy.

5. Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 12:29 p.m., the provided facility's fire safety plan titled "Fire Alarm Response" did not address the following items:
a) Extinguishment of fire. The fire safety plan did indicate the type of fire extinguishers in the building but did not address how to extinguish a fire with an extinguisher.
b) Emergency phone call to fire department. The fire safety plan did not indicate calling the fire department upon discovery of a fire.
Based on interview at the time of records review, the Manager of Plant Operations agreed the aforementioned required items were not included in the fire safety plan.

6. Based on observations during a tour of the facility on Manager of Plant Operations and Maintenance Tech II on 12/17/19 between 12:00 p.m. and 1:00 p.m., the facility's 13 patient sleeping rooms each were provided with 4 hospital grade electrical receptacles. During record review with the Manager of Plant Operations and Maintenance Tech II at 11:14 a.m., there was no documentation available to show electrical receptacles in the patient sleeping rooms were tested after initial installation or if any had been replaced or serviced and then retested.

Based on document review and interview, the facility failed to ensure employees provided proof of vaccination/immunity of Rubella, Rubeola and Varicella for 4 of 9 personnel records reviewed. (N1, N2, N6 and N7)

Findings include:

1. Facility policy titled "Immunization/Tuberculin Screen" with an origin date of 1/17/18 indicated the following: "...Purpose: To facilitate staff's health and to document and be compliant with health regulations. Policy: Staff accessing patient care areas of the general hospital shall maintain pertinent immunization and health records. Immunization Requirements: Prior to performing duties within the patient care environment at the hospital staff shall provide evidence of the following requirements: ...Measles, Mumps, Rubella (MMR)...Documentation of the completed...MMR vaccination, or laboratory evidence of immunity...Varicella...Documentation of two doses of Varicella vaccine, or laboratory evidence of immunity, or written history of Varicella infection from a medical provider. Non-immune persons must complete the vaccine process...New Hire Staff - Must provide Infection Control Nurse with the above documentation prior to assuming duties at the general hospital..."

2. Review of employee N1's (Registered Nurse/Charge Nurse) personnel record indicated the following:
(A) The employee was hired on 10/27/17.
(B) The personnel file lacked documentation of immunity and/or vaccinations for Rubella, Rubeola and Varicella.

3. Review of employee N2's (Psychiatric Technician) personnel record indicated the following:
(A) The employee was hired on 12/27/18.
(B) The personnel file lacked documentation of immunity and/or vaccinations for Rubella, Rubeola and Varicella.

4. Review of employee N6's (Licensed Practical Nurse) personnel record indicated the following:
(A) The employee was hired on 3/15/10.
(B) The personnel file lacked documentation of immunity and/or vaccinations for Rubella, Rubeola and Varicella.

5. Review of employee N7's (Registered Nurse/Infection Control Nurse) personnel record indicated the following:
(A) The employee was hired on 3/3/03.
(B) The personnel file lacked documentation of immunity and/or vaccinations for Rubella, Rubeola and Varicella.

6. During an interview with N7 on 12/18/19 at 5:27 p.m., he/she verified the lack of documentation of immunity and/or vaccinations for Rubella, Rubeola and Varicella for N1, N2, N6 and N7.

I. Provide psychosocial Assessments (facility labeled Diagnostic Evaluation) that met professional social work standards for four of four active sample patients (A1, A2, A3, and A4). These assessments failed to include conclusions and individualized treatment recommendations based on the data documented in the psychosocial assessment. Also, the anticipated social work roles during inpatient treatment and discharge planning were not identified. These failures have the potential to result in a lack of professional social work treatment services and a lack of input to the treatment team to assist in the care of the patient during hospitalization. (See A1625).

II. Include all disciplines responsible for active treatment interventions in the Master Treatment Plans (MTP). Specifically, there were no physician interventions in the MTP for three of four active sample patients (A1, A3, and A4) and no social work and recreational therapist intervention for four of four active sample patients (A1, A2, A3, and A4). This practice results in the failure to define essential professional personnel necessary for active treatment. (See A1643 II).



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III. Provide therapeutic programming for one of four active sample patients (A2) who was allowed to stay in his/her room instead of going to activities. There were no alternatives interventions implemented when the patient was unable or unwilling to participate or if the activity was canceled. This patient was not provided active treatment at the frequency and intensity necessary for psychiatric hospital treatment. Failure to offer therapeutic programming that focuses on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization. (See A1650 I).

IV. Provide professional therapeutic programming for all the patients seven days a week, including evenings and weekends. The activities offered to patients were diversional or leisure in focus and did not address the identified psychiatric needs of the patients. Psychiatric Technicians provided all scheduled activities except for the one group provided by a Social Worker Monday through Friday and only when this social worker was working. No other disciplines led groups. Patients were allowed to sleep or stay in their room instead of going to activity groups, and some activity groups were canceled. Failure to offer groups that focus on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization. (see A1650 III).

Based on medical record review, policy review, and interview, the facility failed to provide psychosocial Assessments (facility labeled Diagnostic Evaluation) that met professional social work standards. These assessments failed to include conclusions based on the data documented in the psychosocial assessment. They failed to include individualized treatment recommendations that described anticipated social work roles during inpatient treatment and discharge planning for four of four active sample patients (A1, A2, A3, and A4). These failures have the potential to result in a lack of professional social work treatment services and a lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings include:

A. Medical Records

The following active sample patients all had Psychosocial Assessments (dates of assessments in parentheses) that failed to list conclusions and recommendations for treatment while in the hospital: Patient A1(12/13/19); Patient A2 (11/21/19); Patient A3 (12/13/19); and Patient A4 (11/17/19).

B. Policy Review

There was no specific facility policy regarding the Psychosocial Assessment. Also, a Hospital Training Document, dated 5/20/14, did not list a requirement for including conclusions and recommendations within the body of the assessment.

C. Interviews

1. In an interview on 12/17/19 at 9:15 a.m., the Medical Director concurred with the findings of the lack of conclusions and recommendations within the Psychosocial Assessment.

2. In an interview on 12/17/19 at 10:15 a.m., the Director of Social Work concurred with the findings of the lack of conclusions and recommendation treatment in the Psychosocial Assessment.

Based on medical record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for four of four active sample patients (A1, A2, A3, and A4). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient attributes in the therapy.

Findings Include:

A. Medical Record Review

The following active sample patients all had Psychiatric Evaluations (dates of evaluations in parentheses) that failed to identify patient assets that could be utilized to assist in the development of treatment modalities in the patients' treatment plans. Patient A1, (12/14/19); Patient A2, (11/21/19); Patient A3, (12/11/19); and Patient A4 (11/17/19).

B. Interview

In an interview on 12/17/19 at 9:15 a.m., the Medical Director concurred with the finding of the absence of assets listed within the information contained in the Psychiatric Evaluations.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered long- term and short-term goals stated in observable, measurable, and behavioral terms for four of four active sample patients (A1, A2, A3, and A4). Lack of measurable patient-specific goals hampers the treatment team's ability to assess changes in the patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

A. Medical Record Review

1. Patient A1's MTP, dated 12/16/19, listed for the Problem Statement "Suicide Risk for [sic]"
the following non-measurable long-term goals (LTG) and short-term goals (STG):

LTG: "Patient will remain safe on IPU [Inpatient Psychiatric Unit], not attempting any self-harm or suicide and contract for safety while on IPU [Inpatient Unit]."
STG: "Be able to think clearer, not have these thoughts." (These long and short term goals were not measurable and addressed only behaviors related to the time period on the unit.)

2. Patient A2's MTP, dated 11/22/19, listed for the Problem Statement "General Drug and Alcohol Education," the following goals:

LTG: "Patient will not use synthetic drugs and will be able to verbalize the negative health effects of tobacco on physical health."
STG: "I want to go home." (The Problem Statement was an intervention and the LTG and STG were not measurable).

3. Patient A3's MTP, dated 12/11/19, listed for the Problem Statement "Suicide risk for [sic]" the following goals:

LTG: "Client will deny suicidal ideation and remain engaged with treatment plan."
STG: "Client states 'goal is not to be depressed.'" (These goals were not measurable or observable).

4. Patient A4's MTP, dated 11/20/19, listed for the Problem "Hopelessness/worthlessness" the following goals:

LTG: "Patient will be able to talk and function in normal society and will follow up with outpatient service at [sic] requested."
STG: "Patient is unable to give short term goal at this time d/t [due to] his/her inability to speak at this time." (These goals were not measurable or observable).

B. Policy Review

The Hospital Procedure revised 4/18, numbered #501, listed the following requirement for Treatment Plans: "The team decides what problems will be addressed while on the unit, establish long and short-term goals, develop measurable objectives and specific interventions related to the patient's specific problems and needs ...."

C. Interviews

1. In an interview on 12/17/19 at 8:45 a.m., the Medical Director concurred with the finding that patient goals were not observable or measurable.

2. In an interview on 12/17/19 at 2:30 p.m., the Director of Nursing (DON) understood the need for observable and measurable goals.

Based on record review and interview, the facility failed to:

I. Identify in the Master Treatment Plans (MTP) specific treatment interventions/modalities for registered nurses (RN) that addressed the identified patient's problems for two of four active sample patients (A1 and A3). The treatment interventions were stated in vague terms and were non-individualized generic nursing functions rather than directed at specific interventions for presenting or current psychiatric symptoms.

II. Include all disciplines responsible for active treatment interventions in the MTP. Specifically, there were no physician interventions in the MTP for three of four active treatment patients (A1, A3, and A4). Physicians had no assigned treatment responsibilities in these treatment plans. This practice has the potential for staff to rely on verbal communications of the physician's plans for treating each patient, an unreliable method which can create misinterpretation of the physician's plan of care. There were also no social worker and recreational therapist interventions listed in the treatment plans for four of four patients (A1, A2, A3, and A4). This practice results in the failure to define essential professional personnel necessary for active treatment.

The above deficiencies also result in the failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings Include:

I. Routine RN Interventions

A. Medical Record Review

1. Patient A1's MTP, dated 12/16/19, listed for the Problem Statement "Suicide Risk for [sic]" the following non-measurable long-term goals (LTG) and short-term goals (STG):
(LTG): "Patient will remain safe on IPU [Inpatient Psychiatric unit], not attempting any self-harm or suicide and contract for safety while on IPU." (STG): "Be able to think clearer, not have these thoughts." For these goals, the following generic nursing job description interventions were listed:

"Staff will monitor for safety every 15 minutes as required."
"Staff will monitor per Elopement Precautions as ordered by Dr."

2. Patient A3's MTP, dated 12/11/19, for the Problem Statement "Suicide risk for [sic]" listed the following goals: LTG: "Client will deny suicidal ideation and remain engaged with treatment plan." STG: "Client states 'goal is not to be depressed.'" For these goals, the following generic nursing job description interventions were listed:

"Staff will maintain a safe and supportive environment."
"Staff will monitor for safety every 15 minutes as required."

B. Interviews

1. In an interview on 12/17/19 at 8:45 a.m., the Medical Director concurred with the finding that nursing interventions were generic and job description duties.

2. During an interview on 12/17/19 at 1:00 p.m., the DON confirmed that the nursing interventions were routine nursing tasks.

II. Failure to include all disciplines interventions

A. Medical Record Review

1. Physician Interventions
A review of MTPs (dates of plans in parentheses) showed that plans for the following active patients did not indicate the treatment interventions for which physicians were responsible: Patient A1 (12/16/19); Patient A3 (12/11/19); and Patient A4 (11/22/19).

2. Social Work Interventions
A review of MTPs (dates of plans in parentheses) revealed that there no trained Social Workers providing treatment interventions in the MTP for the following patients: Patient A1 (12/16/19); Patient A2 (11/22/19); Patient A3 (12/11/19); and Patient A4 (11/22/19).

3. Recreational Therapy Interventions
A review of MTPs (dates of plans in parentheses) revealed that there no recreational therapy treatment interventions in the MTP for the following patients: Patient A1 (12/16/19); Patient A2 (11/22/19); Patient A3 (12/11/19); and Patient A4 (11/22/19).

B. Interviews

1. In an interview on 12/17/19 at 9:15 a.m., the Medical Director concurred with the findings that treatment plans did not always indicate the treatment interventions for which physicians were responsible.

2. In an interview on 12 /17/18 at 19:15 a.m., the Director of Social Work concurred with the findings that there were no trained Social Workers providing treatment interventions in the MTP. In the same interview, s/he indicated there were no trained recreational therapy personnel who added treatment interventions to the MTP.

3. In an interview on 12/17/19 at 2:30 p.m., Clinical Care Coordinators 1 and 2 clearly stated that their function was to arrange for all the issues related to discharge planning. They both clearly said, "We are not therapists and work under the supervision of the Director of Social Work." They shared that they were Bachelor level, psychology majors.

Based on document review, observations, and interview, the facility failed to provide:

I. Active treatment and therapeutic programming, including alternative interventions for one of four active sample patients (A2). Due to acute mental illness, this patient was unable or unwilling to participate in the scheduled activities, and there were no alternative interventions offered to the patient. Patient A2 was also allowed to stay in his/her room instead of going to activities or alternatives if the activity was canceled. This patient was not provided active treatment at the frequency and intensity necessary for psychiatric hospital treatment. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

II. Therapeutic activity assessments for four of four active sample patients (A1, A2, A3, and A4). Therefore, the facility failed to ensure that activity assessments were available to provide appropriate input into the formulation of the Master Treatment Plans (MTPs), as well as to offer therapeutic activities. This failure results in patients not receiving a full complement of therapies, patients not being assessed adequately regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities.

III. Therapeutic programming for all the patients seven days a week, including evenings and weekends. The activities offered to patients were diversional or leisure in focus and did not address the identified psychiatric needs of the patients. Psychiatric Technicians provided all scheduled activities except for the one activity provided by a Social Worker Monday through Friday and only when the social worker was working. No other disciplines led groups. Patients were allowed to sleep or stay in their rooms instead of going to groups and when groups were canceled. Failure to offer groups that focus on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization

Findings include:

A. Document Review

1. A review of the medical record showed that the facility did not have documented evidence that Patient A2 attended any of the scheduled groups or activities. In addition, there was no evidence that alternative individual or group sessions were provided or offered.

2. A review of the medical records revealed activity therapy staff failed to complete activity therapy assessments for the following active sample patients (A1, A2, A3, and A4). There were no activity therapy assessments provided to obtain information regarding the needs, interests, and possible barriers to an activity necessary to formalize individualized therapeutic activity therapy interventions to be included in MTPs.

3. The facility did not have documentation to review regarding alternative individual or group interventions when groups were canceled, or patients did not attend.

4. A review of an undated Activity Schedule revealed the following list of activities: "Therapeutic activity," Exercise activity," and "Relaxation activity in lounge area." The schedule also included meals, vital signs, snacks, visitations, telephone, and TV/Radio as scheduled programming.

B. Observations

1. During an observation on 12/16/19 at 9:00 a.m., A2 was in his/her room sitting on the bed during the scheduled "Therapeutic activity." There was no alternative activity offered or provided for this canceled group.

2. During an observation on 12/17/19 at 2:20 p.m., the census was six patients. Two patients were in bed, one patient was talking to an MHT, and two patients were watching TV. The sixth patient, A5 (a non-sampled patient), was on the Adolescent Unit. RN2 indicated that there had been a behavioral problem with two patients, and therefore the MHT was not able to conduct the scheduled "Therapeutic Activity."

C. Interviews

1. In an interview on 12/17/2019 at 10:30 a.m., the Director of Social Work, who was the supervisor of recreational therapy, reported there was only one Recreational Therapist (RT) for the inpatient hospital. She also said that the only responsibility the RT had was training Psychiatric Technicians on how to conduct groups.

2. In an interview on 12/17/19 at 10:30 a.m., the CTRS1 (Certified Therapeutic Recreational Specialist) reported to the survey team that she only provides training and gives the psychiatric technician materials to use in groups. When asked her/him how the groups were organized and structured, s/he stated, "I don't know."

3. In an interview with SW2 on 12/16/19 at 10:50 a.m., she told the survey team she only does one group Monday-Friday, and today she focused on "how eating walnuts helps depression ..." She stated, "I am getting really good at google, looking for group materials." She reported she was on vacation November 1-5, 2019, and the first week in December, and her group was covered by a psychiatric technician and not a social worker. She also stated, "I will go to the rooms and invite patients to groups, but they can choose not to attend." She confirmed there were no alternatives offered to patients if they refuse or do not participate. She also mentioned that A2 did not attend groups.

4. In an interview on 12/17/19 at 10:30 a.m., the Director of Social Work confirmed that there was only one Social Services group five days per week when the employee was present and that there was no social worker to provide the evening or weekend groups.

Based on record review, observation, and interview, the facility failed to provide:

I. Adequate numbers of social work personnel to provide social work treatment interventions in individual or group sessions with the patients. There were no social work interventions listed treatment plans for four of four active sample patients (A1, A2, A3, and A4). This practice reflects the lack of the provision of services essential for patient's treatment and has to potential to delay the patient's stay in the hospital. (See A1717).

II. An adequate number of therapeutic recreational staff to provide therapeutic activities and rehabilitative services based on patients' needs and interests. Specifically, the facility did not deploy activity therapy staff to provide therapeutic activities on evenings or Saturday and Sunday. These failures result in patients not receiving a full complement of therapies, and patients not receiving individualized and goal-directed activity therapies. (See A1726).

III. Adequate numbers of therapeutic recreational staff to provide therapeutic programming to meet the needs of restoring and maintaining optimal levels of functioning for all active sample patients (A1, A2, A3, and A4). Specifically, there were limited numbers of therapeutic activities for significant periods during the dayshift and no therapeutic activities on evenings and weekends. This lack of active therapies results in these patients being hospitalized without all interventions for the patient recovery provided to them, potentially delaying their discharge. (See A1725).

Based on medical record review, and interview, the Medical Director failed to ensure:

I. The provision of psychiatric evaluations that included an assessment of patient assets in descriptive fashion for four of four active sample patients (A1, A2, A3, and A4). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the attributes in the therapy. (See A1637).

II. Identification of physician interventions in the MTP for three for four active sample treatment patients (A1, A3, and A4). Physicians had no assigned treatment responsibilities on these treatment plans. This practice has the potential for staff to rely on verbal communications of the physician's plans for treating each patient, an unreliable method which can create misinterpretation of the physician's plan of care. (See A1643 II).

III. Therapeutic programming for one out of four active sample patients (A2) who were allowed to stay in their room instead of going to activities, or the activity was canceled. This patient was not provided active treatment at the frequency and intensity necessary for psychiatric hospital treatment. Failure to offer therapeutic programming that focuses on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization. (See A1650 I)

IV. Therapeutic programming for all the patients seven days a week, including evening times. The activities offered to patients were recreational or leisure in focus and did not address the identified psychiatric needs of the patients. Scheduled activities were provided by Psychiatric Technicians except one activity provided by a Social Worker Monday through Friday and only when this social worker was working. No other disciplines led groups. Patients were allowed to sleep or stay in their rooms instead of going to groups. Groups were canceled and no alternatives were provided. Failure to offer groups that focus on identified patient needs limits the patients' ability to recover and can extend the period of hospitalization. (See A1650 III).

Based on medical record review and interview, it was determined the Director of Nursing failed to provide adequate oversight to ensure quality nursing services. Specifically, the Director of Nursing failed to ensure the development of Master Treatment Plans (MTPs) that included nursing interventions with a specific focus based on individual needs and abilities of four of four active sample patients (A1, A2, A3, and A4). The interventions listed in the MTPs included routine RN functions that were required for all patients regardless of assessed needs and reason for admission or continued hospitalization. Some intervention statements failed to include a delivery method. Many statements were similarly worded for patients with different needs. These treatment plans failed to provide guidance for the staff in delivering active treatment that is purposeful and goal orientated. Such failure potentially results in treatment that is inconsistent and ineffective and has the potential to prolong hospitalization.

Findings include:

A. Medical Record Review

A. Patient A1's MTP, dated 12/16/19, listed routine nursing RN functions as active interventions for the following Problem Statements:

Interventions for the problem of "Suicide Risk for [sic]" were:
1. "Staff will monitor for safety every 15 minutes as required."
2. "Staff will monitor per Elopement Precautions as ordered by Dr."

Interventions for the problem of "Hopelessness/Worthlessness" were:
1. "Staff will support quiet milieu at bedtime."
2. "Staff will encourage patient to take medications as ordered and provide medication education."

B. Patients A2's MTP, dated 11/22/19, listed deficient intervention statements and routine nursing RN functions as active interventions for the following Problem Statements:

Interventions for "General Medical Problems" were:
1. "Staff will offer medication education, side-effects, and proper usage."
2. "Staff will encourage patient to take medications and provide medication education." (The intervention statements regarding medication education failed to include how the education would be delivered [group or individual sessions], the name of the medication(s) to be addressed, and did not identify a focus of treatment for the intervention.

Interventions for the problem of "Altered Thoughts" were:
1. "Staff will offer mood stabilizing medication as prescribed by Dr."
2. "Staff will encourage patient to take medications and provide medication education."

C. Patient A3's MTP, dated 12/11/19, listed deficient and routine nursing RN functions as active interventions for the following Problem Statements:

Interventions for the problem of "Suicide risk for [sic]" were:
1. "Staff will monitor for safety every 15 minutes as required."
2. "Staff will provide safe milieu."
3. "Staff will review treatment plan at beginning of shift." (These statements were all routine RN functions.)

Interventions for the problem of "Hopelessness/Worthlessness" were:

1. "Staff will offer mood stabilizing medications as prescribed by provider." (This was a routine RN function.)
2. "Staff will help patient plan coping with stress situations." (This intervention statement was not individualized and failed to include whether they would be delivered in individual or group sessions.

Interventions for "General Medical Problems" were:
1. "Staff will encourage patient to take medications and provide medication education."
2. "Staff will take vital signs at least once a shift and then as needed for report." (These intervention statements included routine RN functions, were not individualized, and failed to include whether they would be delivered in individual or group sessions. The intervention regarding medication education failed to include the name of the medication(s) to be addressed and did not include a focus of the intervention.)

D. Patient A4's MTP, dated 11/20/19, listed the following deficient RN interventions for the Problem Statement of "Altered Thoughts":

1. "Staff will provide empathetic listening techniques and realty feedback."
2. "Staff will help patient plan coping with stress situations." (These interventions were broad, not individualized and failed to include whether they would be delivered in individual or group sessions.)

Interview

During an interview on 12/17/19 at 1:00 p.m., the DON, confirmed that the nursing interventions were routine nursing tasks.

Based on medical record review and interview, the Director of Social Work failed to:

I. Provide psychosocial Assessments (facility labeled Diagnostic Evaluation) that met professional social work standards for four of four active sample patients (A1, A2, A3, and A4). These assessments failed to include conclusions and individualized treatment recommendations based on the data documented in the psychosocial assessment. Also, the anticipated social work roles during inpatient treatment and discharge planning were not identified. These failures have the potential to result in a lack of professional social work treatment services and a lack of input to the treatment team to assist in the care of the patient during hospitalization. (See A1625).

II. Ensure that social work interventions were included in the Master Treatment Plans (MTP) for four of four active sample patients (A1, A2, A3, and A4). This practice fails to define essential and necessary social work active treatment interventions to address the psychiatric symptoms and discharge needs of patients. (See A1643 II).

III. Provide adequate numbers of social work personnel to provide social work interventions (individual and group) and to document social work treatment interventions for the patients and on the treatment plans for four of four active sample patients (A1, A2, A3, and A4). This practice reflects the lack of the provision of services essential for patient's treatment and has the potential to delay the patient's stay in the hospital. (See A1717).

Based on medical record review and interview, the facility failed to provide adequate numbers social work personnel to provide social work interventions (individual and group) and to document social work treatment interventions for the patients and in the treatment plans for four of four active sample patients (A1, A2, A3, and A4). This practice reflects the lack of the provision of services essential for patient's treatment and has the potential to delay the patient's stay in the hospital.

A. Medical Record Review

Patient A1's MTP dated 12/16/19, Patient A2's dated 11/22/19, Patient A3's MTP dated 12/11/19, and Patient A4's MTP dated 11/20/19 all did not contain social work interventions for the patients.

B. Interviews

1. In an interview on 12/17/19 at 10:15 a.m., the Director of Social Work confirmed the lack of Social Work interventions in the MTP. She further indicated there was a one hour per day group provided to the patients by a social worker who was only on the Unit for that purpose. In addition, the Director of Social worker also said, if the social worker is absent, the group is then held by the Psychiatric Technician. She further concurred with the finding that there were no social workers assigned to the unit to provide further therapeutic service (individual or group therapy) to the patients.

2. In an interview on 12/18/19 at 10:00 a.m., RN1 confirmed the absence of social work services to patients on the unit.

Based on medical review and interview, the facility failed to provide adequate numbers of therapeutic recreational staff to provide therapeutic programming to meet the needs of restoring and maintaining optimal levels of functioning for all active sample patients (A2, A2, A3, and A4). Specifically, there were limited numbers of therapeutic activities for significant periods during the dayshift and no therapeutic activities on evenings and weekends. Psychiatric Technicians conducted all of these activities. This lack of activity therapies results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their discharge.

Findings include:

A. Document review

The undated Activity schedule listed the following activities available for patients: "Therapeutic activity," "Exercise activity," and "Relaxation activity in lounge area." The schedule also included meals, vital signs, snacks, visitations, telephone, and TV/Radio as scheduled programming.

B. Observation

On 12/17/19 at 2:00 p.m., the "Therapeutic Activity" that was scheduled was canceled. There were two patients in bed, two patients watching TV, and one staff meeting with one patient. The unit staff did not provide an alternative activity for this canceled group.

C. Interviews

1. In an interview on 12/17/2019 at 10:30 a.m., the Director of Social Work, who was the supervisor of recreational therapy, reported there was only one Recreational Therapist for the inpatient hospital. S/he stated the only responsibility the RT had was training Psychiatric Tech on how to conduct groups.

2. In an interview with CTRS1 on 12/17/19 at 10:30 a.m., s/he reported to the survey team that s/he only provides training and gives the psychiatric technicians materials to use in groups. When asked how the groups were organized and structured, s/he stated, "I don't know."

3. In an interview with RN2 on 12/17/19 at 11:30 a.m., when asked how the activities were chosen for the patient population, s/he stated, "The techs will tell me what they did after the activity."

4. In an interview with SW2 on 12/16/19 at 10:50 a.m., s/he told the survey team s/he only does one group Monday-Friday and today s/he focused on "how eating walnuts helps depression ..." She said, "I am getting really good at google, looking for group materials." S/he also reported s/he was on vacation November 1-5, 2019, and the first week in December, and his/her group was covered by a psychiatric tech and not a social worker.

Based on record review and staff interview, the facility failed to provide an adequate number of therapeutic recreational staff to provide therapeutic activities and rehabilitative services based on patients' needs and interests. Specifically, the facility did not deploy activity therapy staff to provide therapeutic activities on evenings or Saturday and Sunday. There were no activity therapy interventions included in the MTPs. There were no rehabilitation assessments completed for use in interdisciplinary treatment planning. These failures result in patients not receiving a full complement of therapies, and patients not receiving individualized and goal-directed activity therapies.

Findings include:

A. Medical Record Review

1. A review of the medical records revealed activity therapy staff failed to perform or document activity therapy assessments for the four of four active sample patients (A1, A2, A3, and A4). There were no activity therapy assessments completed to obtain information regarding the needs, interests, and possible barriers to an activity necessary to formalize individualized therapeutic activity therapy interventions to be included in MTPs.

2. None of the four active sample patients (date of Master Treatment plan in parenthesis) included specific activity therapy interventions in the Master Treatment plan: A1 (11/22/19), A2 (12/16/19), A3 (12/11/19), and A4 (11/17/19). These plans revealed that there were no activity therapy interventions for these patients. (Refer to A1643 II).

B. Interview

In an interview with the Recreational Therapist on 12/17/19 at 10:30 a.m., s/he reported to the survey team, "There are no RT assessments completed, I am not involved with the development of the activity schedule, and I don't know how the program is organized." S/he also stated to the survey team that there was no other CTRS staff, and his/her only responsibility was to train the psychiatric techs.