HospitalInspections.org

The hospital failed 1 of 10 Patients (Patient #2) by failing to inform each patinet, or when appropriate, the patient's representative, of the patient's right, in advance of furnishing or discontinuring patient care.

Findings Include:

During telephone interview the complainant informed the Surveyor that Patient #2 was going to be discharged the day of informing the family of discharge 12/10/2021. The hospital concluded that the Patient would be discharged on following Monday 12/13/2021.

During Record Review, the hospital email thread reflected that the patient was going to be discharged on 12/10/2021, "Complainant is concerned of discharge tomorrow, thinks it is a 'week early.' She is frustrated she has not heard about anybody but has been 'calling for the past 14 hours...Y'all are discharging her the day before finals start. This is going to set her off all over again ...She would like a call back, ASAP ...Pls check with David or Jasmine or look the discharge list I think she is for Monday, it was moved to Monday this morning ...Pt. reported, SI, HI & thoughts of self-harm today in group. Complainant said it was communicated to her that her DC date is tomorrow ...does she has clinical? We still have three days she is not supposed to be discharged till Monday. Will re-evaluate on Monday ...Complainant would like discharge date pushed back. Says pt was biting herself during visitation yesterday and pt. is still reporting clinical. Are we able to push it back?"

Policy
The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing the patient of ther right to participate in the development and implementation of his or her plan of care.

Findings Include:

During Record Review, the hospital failed to complete a Master Treatment Plan within 72 hours of admission (the 3rd day of treatment).

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing the patient of their right to the confidentiality of his or her clinical records.
HIPAA violation.

Findings included:

Through Interview with hospital Staff # 2, confirmed, that the hospital contacted an outside telephone number through text message, and disclosed personal information Patient #2 about medical history and discharge status.

Through Interviw with the complainant, the complaint reported that they had recieved a telephone call from an outside source that indicated Patient #2 would be discharged and personal medical history of Patient #2. The complainant reported this as being a HIPAA violation.

During Record Review the hospital failed to follow its own Policy. The Policy does not indicate that the hospital may submit text messages inregards to patient information.

During record review the hospital failed to follow its own Policy by disclosing confidential information to an unknown source without any means of verification of unauthorized collateral.

POLICY

The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing to provide the patient with an individualized, comprehensive Master Treatment Plan based on an inventory of the Patient's Strengths and disabilitites.

Findings Include:

During Record Review, the Master Treatment Plan revealed the following information filled out. "Date of Admission, Uni the Patient was residing on, Legal Status, Program,, Level of Monitoring, Date initiated, Precautions, Date initiated." No further information required on the Master Treatment Plan was completed.

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

Policy

The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing to include a Master Treatment Plan with a substantiated diagnosis.

Findings Include:

During Record Review, the Master Treatment Plan revealed the following information filled out. "Date of Admission, Uni the Patient was residing on, Legal Status, Program,, Level of Monitoring, Date initiated, Precautions, Date initiated." No further information required on the Master Treatment Plan was completed.

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

POLICY
The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing to complete a Master Treatment Plan that included Short-term and Long range goals.



Findings Include:

During Record Review, the Master Treatment Plan revealed the following information filled out. "Date of Admission, Uni the Patient was residing on, Legal Status, Program,, Level of Monitoring, Date initiated, Precautions, Date initiated." No further information required on the Master Treatment Plan was completed.

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

Policy

The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing to complete a Master Treatment Plan, and include the responsibilities of each member of the treatment team, and participants of the treatment plan.

Findings Include:

During Record Review, the Master Treatment Plan revealed the following information filled out. "Date of Admission, Uni the Patient was residing on, Legal Status, Program,, Level of Monitoring, Date initiated, Precautions, Date initiated." No further information required on the Master Treatment Plan was completed.

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

Policy
The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital failed 1 of 10 Patients (Patient #2) by failing to complete a written Master Treatment Plan adequately documented to justify the diagnosis and the treatment and rehavilitation activities carred out.

Findings Include:

During Record Review, the Master Treatment Plan revealed the following information filled out. "Date of Admission, Uni the Patient was residing on, Legal Status, Program,, Level of Monitoring, Date initiated, Precautions, Date initiated." No further information required on the Master Treatment Plan was completed.

During Record Review, the hospital has failed to follow its own Policy. "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate."

During Interview with hospital Staff #16 the surveyor was informed that the hospital does not include the family or the patient during the treatment plan process. "The treatment plan is implemented through the Psychological Evaluation, and we will inform or communicate the treatment with the parent during visitation. Not when the plan is implemented and put into action."

During Interview with hospital Staff #1 the surveyor has been informed that the hospital has hired a new Clinical Director who while be more about the care and treatment of the patients. The Clinical Director would be starting within the next two weeks.

POLICY
The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital policy on SafeGuarding and Storing Protected Health Information 'HIPAA Privacy' dated 06/15/2019 reflected, "The policy of this Facility is to ensure, to the extent possible, the PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulations governing confidentiality and privacy of health information. The following procedure is designated to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is or will be contained in a patient's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a patient's Medical Record by health care practitioners involved in a patient's care (nurses, attending and consulting physicians, therapist and others) is essential to ensure the efficient quality delivery of health care ...All staff members are responsible for the security of the active Medical Records at the nursing stations...
Telephone conversations:
1. Telephones used for discussing PHI are located in as private an area as possible.
2. Staff members will take reasonable measures to assure that unauthorized persons do not overhear telephone conversations involving PHI. Reasonable measures may include:
a. Lowering voice
b. Requesting that unauthorized person step away from telephone area
c. Move to a telephone in a more private area before continuing to accomplish the purpose of the use or disclosure.

The hospital Policy on Treatment Plan: Interdisciplinary Master Treatment Plan dated 07/17/2019 reflected, "Perimeter Healthcare will provide inpatient mental health treatment to a patient under the direction of a physician in accordance with the patient's treatment plan. Patients admitted to Perimeter Healthcare have an individualized written treatment plan which is based on the interdisciplinary clinical assessments. The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge. The treatment plan shall be appropriate to the interest of the patient continuing through discharge. The treatment plan shall be appropriate to the interest of the patient and directed toward restoring and maintain optimal levels of physical and psychological functioning, as well as preparing for discharge. At the interdisciplinary treatment team planning meetings, goals and objects are established and a discharge and aftercare plan are determined. Both parents and/or their Legally Authorized Representatives (LAR) are to be involved in the treatment planning process as authorized and or appropriate. Each patient shall have an Interdisciplinary Treatment Team (IDT) that possesses the knowledge, skills and expertise to develop and implement a patient's treatment plan. This IDT shall include: the patient's treating physician; the patient; the patient's LAR, if any; staff members identified in the treatment plan as responsible for providing or ensuring the provision of care; any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and other staff members as clinically appropriate. The treatment plan may include but is not limited to diagnosis, dietitian recommendations, problem list, both psychiatric and medical, short-term and long-term goals for each identified problem, interventions to be implemented by each discipline and discharge criteria and aftercare recommendations ...
Interdisciplinary Treatment Planning Meetings will be conducted within 72 hours of admission (third treatment day). The purpose of the interdisciplinary treatment team planning session is to integrate all assessments and incorporate key information and coordinate treatment team and discharge planning."

The hospital Policy on Administration/Personnel dated 07/17/2019 reflected, the direction for the leadership of the facility is established by our mission, values and strategic plan. Our mission is stated as follows:
Mission:
"Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

Facility Leadership:
Chief Executive Director
Medical Director
Chief Nursing Officer
Chief Operations Officer
Director of Clinical Services
Director of Assessment & Referral Services
Director of Business Development
Director Risk & Quality
Leadership Responsibility
The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety. These responsibilities include the follow;
Planning - the formulation of specific goals, structured and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers.
Management - The process of organizing, directing and coordinating the functions of the systems to achieve its goals.
Improvement - The process of regulating service activities to ensure achievement of goals through a continuous performance improvement process.

The hospital Policy on Admission/Transfer/Discharge dated 07/17/2019 reflected, "Perimeter Healthcare administration welcomes all patients who meet criteria for admission. No patient is to be denied admission due to race, color, religion, sexual orientation, ancestry, financial class or national origin. All patients will be accepted for care, cared for and housed without discrimination.
Patients shall be admitted only after an assessment is completed upon referral or walk-in and approved by a physician who shall be a member of the medical staff or has temporary privileges according to the medical staff bylaws. The patient's condition and provisional diagnosis shall be established on admission by the admitting physician."

The hospital Continued Stay and Discharge Criteria dated 07/17/2019 reflected, "Perimeter Healthcare does not discriminate against patients being evaluated or provided care based on religion, race, gender, sexual orientation, and/or other criteria as defined by legislation and/or regulatory standard or statue. It is the policy of the perimeter Healthcare to follow criteria for continued stay and discharge to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."
The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."