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Based on a review of the hospital policy, record review, and staff interviews, the facility failed to complete social service assessments for two (2) of eight (8) sample patients (A1 and A2). The assessments were not on the record at the time of the record review on (6/6/16) nor were the assessments performed in compliance with hospital policy requirements. As a result, the treatment team did not have available the current baseline social functioning of the patient, to be used in establishing goals and interventions for the patient.

Findings Include:

A. Specific Patient Findings:

1. Patient A1, admitted 5/5/16, did not have a social work assessment present on his/her medical record on the first day of the survey (6/6/16). On the 2nd day of the survey a social assessment dated 5/31/16 was presented to the surveyors and was delayed getting on the chart due to a document filing issue. This assessment had not been available to members of the treatment team who were providing care to the patient.

2. Patient A2 admitted on 3/22/16 did not have a social assessment available on the medical record on 6/6/16 nor did the facility demonstrate that the assessment had been done.

B. Policy Review

Hospital Policy "OPERATING PROCEDURE NO 155-16, RECOVERY PLANNING AND IMPLEMENTATION IN MENTAL HEALTH TREATMENT FACILITIES" states in Section 5.h "Comprehensive Psychosocial History will be completed by the social services staff within the first 15 working days of the resident's admission...."

C. Interviews

1. In an interview on 6/6/16 at 1:00 PM, RN3 confirmed that a comprehensive psychosocial history was not present on the medical record of Patient A2.

2. In an interview on 6/7/16 at 10:30 AM, the Director of Social Work and Social Worker 1 confirmed that the comprehensive psychosocial history was not present on the medical record of patient A1.

Based on record review and interview, the facility failed to provide a written plan to direct patient treatment during the first 30 days following admission for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The Stabilization Plan developed within five (5) days of admission listed the same generic interventions for eight (8) of eight (8) active patients (A1, A2, A3, A4, A5, A6, A7 and A8), did not address individual patient needs and allowed patients to attend any group of choice for 30 days. Failure to provide professionally designed treatment goals and interventions has the potential to create unfocused treatment that can extend patients' length of stay.

Findings include:

A. Specific Patient Findings

1. Patient A1 was admitted on 5/5/16. The Stabilization Plan dated 5/12/16 listed the intervention, "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A1's specific needs.

2. Patient A2 was admitted on 3/22/16. The Stabilization Plan dated 3/24/16 listed the intervention, "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." There were no treatment interventions designed for Patient A2's specific needs.

3. Patient A3 was admitted on 1/26/16. The Stabilization Plan dated 1/27/16 listed the intervention "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A3's specific needs.

4. Patient A4 was admitted on 3/10/16. The Stabilization Plan dated 3/12/16 listed the intervention "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A4's specific needs.

5. Patient A5 was admitted on 10/6/15. The Stabilization Plan dated 10/7/16 listed the intervention, "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A5's specific needs.

6. Patient A6 was admitted on 1/26/16. The Stabilization Plan dated 1/27/16 listed the intervention "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A6's specific needs.

7. Patient A7 was admitted 9/29/15. The Stabilization Plan dated 9/30/16 listed the intervention "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A7's specific needs.

8. Patient A8 was admitted 2/23/16. The Stabilization Plan date 2/24/16 listed the intervention "Attend Recovery Center M-F [Monday-Friday] from 9-11 a.m. and 1-3 p.m. for clinical treatment and rehabilitation services." Other than listing ordered medications, there were no treatment interventions designed for Patient A8's specific needs.

B. Interview

1. During interview on 6/7/16 at 2:30 PM, Psychiatrist 1agreed that patients choose their own treatment groups for the first 30 days before the Master Treatment Plan is completed.

2. During interview on 6/7/16 at 3:30 PM, the Director of Nursing acknowledged that the Stabilization Plan did not address individualized treatment goals/interventions and that patients were free to choose their own treatment groups for the first 30 days.

Based on record review and interview, the facility failed develop Master Treatment Plans (MTP) that identified patient-centered short term and long range goals in observable, measurable, behavioral terms for seven (7) of eight (8) active patients (A2, A3, A4, A5, A6, A7 and A8). The lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings Include:

A. Specific Patient Findings

1. Patient A2 admitted on 3/22/16 had listed on the MTP (Master Treatment Plan) dated 4/14/16 for the problem, "SAD [SchizoAffective Disorder], psychosis, aggression, disorganized thoughts, unable to care for self ", the short term goal, "Given medication, monitoring, & therapeutic milieu, [Patient] will use appropriate skills to initiate 1 interaction/day with others by 6/16/16."

2. Patient A3 admitted on 1/26/16 had listed on the MTP dated 2/23/16 for the problem, "Schizophrenia: delusions, command hallucinations, agitation, unable to care for self ", the short term goal, "Given medication, milieu therapy & monitoring, [Patient] will interact with the staff & peers in a socially appropriate manner daily x [times] 1 month by 7/21/16."

3. Patient A4 admitted on 3/10/16 had listed on the MTP dated 4/7/16 for the problem, "Schizophrenia: delusions, paranoia, aggression, poor self-care, isolative", the long range goal, "[Patient's] interactions & decisions will not be negatively influenced by paranoid thoughts by 3/10/17."

4. Patient A5 admitted on 10/6/15 had listed on the MTP dated 11/4/15 for the problem, "Unspecified Major Neurocognitive D/O [Disorder]-hostility, suspiciousness, unusual thought content", the long range goal, "[Patient] will demonstrate an appropriate response to feelings of hostility & suspiciousness, & display effective problem solving skills to stressors for 90 consecutive days prior to DC [discharge] by 10-6-2016."

5. Patient A6 admitted on 1/26/16 had listed on the MTP dated 2/24/16 for the problem, "Schizophrenia-anxiety, conseptual [sic] disorganization, tension, hallucinatory behavior, unusual thought", the short term goal, "Given recovery activities, [Patient] will demonstrate getting needs met by using assertive communication skills no less than 2 days per week by 4/27/16."

6. Patient A7 admitted on 9/29/15 had listed on the MTP dated 10/26/15 for the problem, "Bipolar Affective D/O with Psychosis & Depression vs Schizoaffective D/O, continuous", the long range goal, "[Patient] will demonstrate an appropriate response to feelings of anxiety, withdrawal, & display ability to cope with feelings effectively for 90 consecutive days prior to DC by 9-29-2016."

7. Patient A8 admitted on 2/23/16 had listed on the MTP dated 3/23/16 for the problem, "Major depression, severe, recurrent, w/o [without] psychotic features-emotional withdrawal, depressive mood, uncooperativeness", the short term goal, "Given medication & education, [Patient] will have no medication refusals & will identify irrational thoughts & a plan for a positive outcome no less than 1 time by 5/23/16."

B. Interview

1. During interview on 6/6/16 at 11:45 AM, RN3 stated that the short term and long range goals would be difficult to measure.

2. During interview on 6/7/16 at 2:30 PM, Psychiatrist 1 stated that it was not possible to measure the short term and long range goals for the active sample patients.

Based on record review, policy review, and interview, the facility failed to ensure that patient discharge summaries were completed in a timely fashion defined by hospital policy requirements for three (3) of five (5) discharged patients (D3, D4 and D5). This compromises the effective transfer of the patient's care to the next care provider.

Findings Include:

A. Specific Patient Findings:

1. Patient D3, discharged on 3/17/16, did not have a psychiatric discharge summary on the medical record on 6/7/16.

2. Patient D4, discharged on 4/12/16, did not have a psychiatric discharge summary on the medical record on 6/7/16.

3. Patient D5, discharged on 5/19/16, did not have a psychiatric discharge summary on the medical record on 6/7/16.

B. Policy Review

1 Hospital Policy, "NORTHEAST FLORIDA STATE HOSPITAL PSHYSICIAN SERVICES, OFFICE OF MEDICAL EXECUTIVE DIRECTOR (MED) NEW PHYSICIAN ORIENTATION" states "Discharge summaries should be dictated ideally within 6 days after the person has left."

C. Interviews

1. In an interview on 6/6/16 at 3:00 PM Secretary 1 indicated that the psychiatric discharge summaries for patients D3, D4 and D5 were not present on the patient's medical record.

2. In an interview on 6/7/16 at 2:00 PM, Physician 1 concurred that the psychiatric discharge summaries for D3, D4 and D5 were not present on the listed medical records.

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

The medical record contained complete social service assessments for two (2) of eight (8) sample patients (A1 and A2). The assessments were not on the record at the time of the record review on (6/6/16) nor were the assessments performed in compliance with hospital policy requirements. As a result, the treatment team did not have available the current baseline social functioning of the patient, to be used in establishing goals and interventions for the patient. (See B108)

2.The provision of a written plan to direct patient treatment during the first 30 days following admission for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The Stabilization Plan developed within five (5) days of admission listed the same generic interventions for eight (8) of eight (8) active patients (A1, A2, A3, A4, A5, A6, A7 and A8), did not address individual patient needs and allowed patients to attend any group of choice for 30 days. Failure to provide professionally designed treatment goals and interventions has the potential to create unfocused treatment that can extend patients' length of stay. (See B118)

3. The development of Master Treatment Plans (MTPs) that identified patient-centered short term and long range goals in observable, measurable, behavioral terms for seven (7) of eight (8) active patients (A2, A3, A4, A5, A6, A7 and A8). The lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs. (See B121)

4. The presence of patient discharge summaries on the medical record and completed in a timely fashion, defined by hospital policy requirements, for three (3) of five (5) discharged patients (D3, D4 and D5). This compromises the effective transfer of the patient's care to the next care provider. (See B133)