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Based on record review and interview, the facility failed to provide a psychiatric evaluation for 6 of 9 active sample patients (P2, P3, P4, P6, P7 and P9) that contained an inventory of patient strengths/assets. The strengths/assets were not documented or were external resources rather than strengths/assets that the patients brought to treatment. This failed practice negatively impacts the treatment planning process, which may result in inappropriate treatment goals and activities.

Findings include:

A. Record review

1. Patient P2. The psychiatric evaluation of 6/13/2011 listed patient's assets as "Supportive Family."

2. Patient P3. The psychiatric evaluation of 6/1/2011 lists patient's assets as "Family involved."

3. Patient P4. The psychiatric evaluation of 6/14/2011 had no documentation of patient's assets.

4. Patient P6. The psychiatric evaluation of 6/20/2011 listed patient's assets as "mother is involved in the care."

5. Patient P7. The psychiatric evaluation of 6/17/2011 listed patient's assets as "supportive husband."

6. Patient P9. The psychiatric evaluation of 6/19/2011 listed patient's assets as "Family is involved in her care."

B. Staff interview

During an interview on 6/22/2011 at 8a.m., the Medical Director concurred that patients' assets need to be more specific and individualized.

Based on record review and interview, the facility failed to develop a Master Treatment Plan for 1 of 9 active sample patients (P1) that included focused interventions that correlated with identified patient problems and goals. This failure hampers the treatment team's ability to provide and evaluate treatment based on patient's presenting needs and behaviors.

Findings include:

A. Record Review

Patient P1's psychiatric evaluation dated 6/18/2011 included "polysubstance dependence, including marijuana, opiates, alcohol, and cocaine" as a diagnosis. The problems to be addressed during hospitalization" included "1. Multiple substance use." The patient's Master Treatment Plan, dated 6/20/11, did not include anything related to the polysubstance abuse problems identified in the psychiatric evaluation.

B. Interviews

1. In an interview on 6/21/11 at 11:30a.m., S1 and S2 agreed that the problems identified in the psychiatric evaluation of sample patient P1 should have been included in the Treatment Plan.

2. In an interview on 6/21/11 at 11:00a.m., MD1 stated, "The Treatment Plan (for Patient P1) should have addressed interventions for polysubstance dependence."

Based on the record review and staff interview, the facility failed to ensure that the discharge summaries for 3 of 5 discharged patients (D1, D2 and D4) were completed in a timely fashion defined by the hospital policy requirements (30 days). This failure compromises the effective transfer of the patient's care to the next provider.

Findings include:

A. Record review:

1. Patient D1 was discharged on 4/26/2011. Her discharge summary was dictated and typed on 6/21/2011.

2. Patient D2 was discharged on 4/26/2011. His discharge summary was dictated on 6/16/2011 and typed on 6/18/2011.

3. Patient D4 was discharged on 4/26/2011. His discharge summary was dictated and typed on 5/31/2011 and signed (electronic) by the physician on 6/3/11.

B. Staff interview:

In an interview on 6/21/2011 at 1:30p.m., the Medical Records Director acknowledged that for three of the five reviewed discharged records (D1, D2 and D4), the discharge summaries did not meet the hospital defined timeframe of thirty days for completion.

C. Additional Document Review

Review the hospital medical record statistics forms for the past 12 months revealed that, on average, forty one (41) patient discharge summaries per quarter (3 months) were not completed in a timely manner per hospital policy.

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

I. Assure that the psychiatric evaluations for 6 of 9 active sample patients (P2, P3, P4, P6, P7 and P9) contained an inventory of patient strengths/assets. The strengths/assets were not documented on the psychiatric evaluations or were listed as external resources rather than strengths/assets that the patients brought to treatment. This failed practice negatively impacts the treatment planning process, which may result in inappropriate treatment goals and activities. (Refer to B117)

II. Assure that the discharge summaries for 3 of 5 discharged patients (D1, D2 and D4) were completed in a timely fashion as defined by hospital policy requirements (30 days). This failure compromises the effective transfer of the patient's care to the next provider. (Refer to B133)

Based on record review and interview, the facility failed to employ a Director of Social Services or utilize a master level social worker (MSW) to monitor and evaluate social services on the inpatient units. This failed practice can result in lack of needed social work services for hospitalized patients.

Findings include:

A. Record review

A review of the hospital's organizational chart showed that there was no job assignment for a Director of Social Services for inpatient services.

B. Staff interview

1. During an interview on 6/21/11 at 11:30 a.m., the Director of Social Services (SW1) stated that he "does not oversee inpatient social services." Further he stated he does not supervise SW2 or SW3.

2. In the same interview as above (6/21/11; 11:30a.m.), SW2.who was substituting for the "Director of clinical inpatient therapists" (SW3), acknowledged that the LCSW's (Licensed Certified Social Workers) and the LCPC's (Licensed Certified Counselors) report to the SW3 (a social worker who does not have a masters degree).

3. During an interview on 6/21/11 at 3:40p.m., the Director of Psychiatric Specialty Services acknowledged that the licensed social workers and counselors report to the Director of Clinical Inpatient Therapists (SW3) who does not have a master degree in social work (MSW).