HospitalInspections.org

Based on interview and record review the facility failed to implement timely performance improvement plans to address problem areas related to provision of therapeutic activities and groups identified through data collection.

Findings included:

1. On 8/10/2022 at 11:50 a.m., the Vice President for Quality was interviewed.

A. The psychiatric hospital's "County Report Measures FY 2021-2022" was reviewed with Vice President of Quality (VPQ). The VPQ stated the data on the report was based on audits the hospital conducted from October 2021. The confirmed the data indicated in the "Baker Act Adult" and the "inpatient Detox" sections were representative of the psychiatric hospital patients. The document indicated:

a. "Baker Act Adult Milestone 2: Participant will be provided and encouraged to engage in individual, group, and/or family therapy to discuss warning signs/triggers an coping skills/tools to manage distressing mental health symptoms, prevent relapse, and improve family dynamics and interpersonal relationships."
-Quarter 1: 55%
-Quarter 2: 30%
-Quarter 3: 34%

b. "Inpatient Detox Milestone 4: Client will identify warning signs/triggers of relapse and coping skills, tools and support system for recovery by engaging in individual and/or group therapy."

-Quarter 1: 87%
-Quarter 2: 67%
-Quarter 3: 78%

B. The survey initial findings regarding therapeutic activities, both individual and groups and the quality data from the report were discussed with the VPQ.

C. The VPQ was able to verbally provide plans to be implemented but was unable to provide written and implemented performance improvement plans addressing the problem areas related to provision of therapeutic activities and groups identified.

Based on record review and interviews the facility did not ensure that a stat order for an EKG (electrocardiogram) was completed for one patient (#10) of ten sampled patients.

Findings included:

Patient #10 was admitted to the hospital on 3/2/22 with a diagnosis of unspecified reactive psychosis, according to review of the face sheet in the admission record.

Review of a grievance dated 3/29/22, written and submitted by Patient #10, reflected she had complained of chest pains and was "denied healthcare."

Review of a Med Evaluation progress note in the medical record, entered by the psychiatric resident DO (doctor of osteopathy) dated 3/8/22 at 9:30 AM revealed the following relevant information:
Patient reports last night c/o (complaint of) chest pain, and states nursing staff didn't address it. Patient just describes her chest pain as heaviness, and seems to correlate with her anxiety. Currently vital signs are within normal limits, however treatment team will be ordering an EKG for her, as she reports a history of tachycardia. Will order EKG.

Review of the Cardiology Exam Order Form dated 3/8/22 reflected an EKG was ordered "Stat".

Review of the nursing progress note dated 3/8/22 2:00 PM showed "Client attending physician ordered an EKG STAT due to complaints of chest pain." There were no further notes indicating the EKG had been completed or that the attending had been notified of the result.

At 2:18 PM on 8/10/22 an interview was conducted with the risk manager (RM).She said the nurse managers do five audits of the treatment plan per week. Medical records audits every chart. She was not sure how long the audits have been going on. They have always done them. Medical records always reports. She has been doing them for years. Audits are discussed in three of the four monthly meetings.

At 11:33 AM on 8/11/22 another interview was conducted with the RM, and the quality management coordinator (QMC).The QMC said Patient #10 called the risk manager and said that she does not want to talk to anyone and is hiring an attorney at this time due to us putting her life in danger. We sent her a certified letter. The RM said the attending ordered an EKG on 3/8. [Mobile Diagnostic Company Name] comes here. The doctor documented her vital signs were within normal limits. She reports a history of tachycardia and was complaining of chest pain. She describes it as heaviness from anxiety. That was the reason for the EKG. It was ordered on 3/8 at 2:00 PM. They (Mobile Diagnostic Company Name) usually come that day; usually within four hours. It was ordered stat. "I just don't see the EKG." Patient #10 left the next morning. There were no notes that she complained to the nursing staff. The next morning the doctor's evaluation doesn't say anything about her chest pain or EKG. Nursing reported no events overnight. The EKG would go through nursing and medical staff. The [Mobile Diagnostic Company] came on 3/9 to do the EKG and Patient #10 was discharged. The RM said she was not aware the EKG had not been done until today.

In a follow up interview with the risk manager at 1:15 PM on 8/11/22 she confirmed the EKG was not done. She stated that they came to do it the next day and Patient #10 was discharged. Stat means the same day. It should have been done the day it was ordered.

Based on observation and staff interview the facility failed to ensure ice machine equipment was maintained to ensure an acceptable level of safety and quality for one of one ice machines located in the facility.

Findings included:

On 8/10/22 at 11:15 AM a tour of the facility kitchen was conducted with the director of dietary services. The ice bin was observed during the tour. Located on each of the corners, where the shield was attached to the wall of the bin, were two screws covered with rust-colored biogrowth. There was additional rust-colored biogrowth alongside and around the screws extending to the plastic walls near the screws. *Photographic evidence was obtained. The director of dietary services said he was not aware of it before today. The ice machine is cleaned every week. The contractor does a deep clean every month also.

At 1:24 PM on 8/10/22 in a follow up interview with the director of dietary services said he put in a work order.

Review of the Dietary Monthly Infection Control Inspection dated 7/8/22, reflected the biogrowth had not been identified.

A review of the ice machine cleaning schedule revealed it was last cleaned on 7/21/22.

At 1:53 PM on 8/10/22 an interview was conducted with the risk manager (RM). She said she does a walk through every month and she checks the cleaning sign-off sheet. She didn't see the biogrowth in there in June. She looks for things like mold and mildew. She has never seen that before. The department of health (DOH) was here last week and it wasn't there.

On 8/11/22 at 12:11 PM an interview was conducted with the director of facilities. He said anything from the roof to the basement should be in my department. The biogrowth was brought to his attention today. He said he doesn't know who put those screws in there. He put a stainless steel in there today and cleaned it up. The plastic is stained now. He took it apart and tried to scrub it with a cleanser. It is stained. It is going to be there until we order a new shield or ice bin. The RM showed it to him. "The color isn't the problem. The problem is the rust is coming off. I used a paper towel and showed her the rust on it. I had them empty out the ice, clean and sanitize it and turn it back on after that. That rust has been there for months or maybe years." Since he has been here, the Dietary Management Company has taken over. They are outsourced. "I was under the impression they are taking care of the equipment. They aren't doing it as they should. We'll be developing a program between maintenance and their staff so nothing falls through the cracks."

Based on observation, staff interview, and medical record review the facility failed to maintain clinical records sufficient to determine the degree and intensity of treatment furnished to three (Patient #3, #4, and #5) of ten sampled patients. The medical records of Patient #3, #4, and #5 did not contain sufficient information, including but not limited to:
1. Completed, individualized and comprehensive treatment plans with an adequate inventory of their assets/strengths and,
2. Specific clinical/psychiatric treatment programs (i.e., individual, group, therapeutic activities, therapeutic procedures, rehabilitative services) provided and documentation of the patient's response.

Findings included:

1. Review of the MR (medical record) for Patient #3 with the Hospital Nurse Manager (NM) indicated the following:

A. The Patient was a 40-year-old woman who was admitted on 8/5/2022 to the psychiatric hospital on an involuntary basis for "bizarre behavior and voicing homicidal ideations towards her neighbors outside her home". The patient was discharge from the psychiatric hospital on 8/8/2022. The patient's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) with psychotic features and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

B. The Psychiatric Evaluation dated 8/5/2022 indicated, " ...Her behaviors towards them (neighbors) have resulted in multiple encounters with the police. At one time she exposed her genitalia to her next-door neighbor ...Most recently, she got in a verbal confrontation with a neighbor and at one point threatened to stab him with a knife ..." The evaluation further indicated " ...The patient consistently exhibits paranoid delusions, splitting, labile affect, flight of ideas ..."

C. The Treatment Plan dated 8/5/2022 indicated:

-Problem: Adjustment disorder, Goal: "I am not suicidal. I shouldn't be here", Objective: "I need to be released", Interventions: MD (doctor) will evaluate client and determine what medications will help client, RN (registered nurse) will educate client on medications prescribed, client will report any side effects of medication taken.

-Problem: Pain, Goal "After the morphine wears off I'll be in constant pain", Objective: "I take medical marijuana for the pain, but I've been out for 2 weeks", Intervention: Pain assessment will be performed as ordered for client; MD will prescribe medications to help client with the pain; Client will have pain 0-4 on a scale of 0-10.

-Problem: Discharge planning issues. The problem did not have a goal. The problem did not have any objectives nor interventions.

-The area "Strengths and Challenges" was blank.

-The treatment plan did not identify the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

2. Review of the MR for Patient #4 with the NM indicated the following:

A. The patient was a 53-year-old male admitted on 8/7/2022 to the psychiatric hospital on an involuntary basis for "homicidal ideation". The patient's diagnosis included persistent complex bereavement disorder with psychotic features, PTSD and alcohol abuse.

B. The Psychiatric Evaluation dated 8/8/2022 indicated, " ...Patient states he began binge drinking on Friday and drank continually through the weekend ...The patient stated to the police that he plans to eventually murder his brother-in-law as an act of revenge and consuming his remains..." The evaluation further indicated "Plan ...Order individual therapy ...Encourage participation in group therapy sessions as inpatient, provide therapeutic milieu ..."

C. The Treatment Plan dated 8/7/2022 indicated:
-Problem: ETOH (alcohol) dependence, Goal: I will stay away from alcohol after DC, Objective: I will discuss the circumstances of my addiction (PTSD); I will report any s/s of withdrawal to the nurse, Intervention: Nurse will assess patient daily for s/s (signs and symptoms) of alcohol withdrawal; BHT will encourage client to attend therapy and all educational groups offered.

-Problem: Post traumatic stress disorder, Goal: I will be free of PTSD symptoms after DC, Objective: I will participate in therapies to know how to manage my PTSD symptoms such as flashbacks, insomnia, mood instabilities, among others; MD will prescribe me medication to help me with the symptoms combining with psychotherapies, Intervention: Nurse will administer medication as prescribed by MD; MD will prescribe medication to help with symptoms of PTSD.
-Problem: Discharge planning issues, Goal: I want to live somewhere I am supported, Objective: I will establish an outside support system prior to discharge; I will follow up with outpatient services as recommended by my doctor; I will discharge to a safe environment, Intervention: CM (case manager) will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in identifying personal and community support x 1 and as needed x 7 days.

-The area "Strengths and Challenges" was blank.

-The treatment plan did not indicate specific treatment programs to address the patients psychiatric therapeutic needs.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

3. Review of the MR for Patient # 5 NM indicated the following:

A. The patient was a 61-year-old male admitted on 8/6/2022 to the psychiatric hospital on an involuntary basis for suicidal ideation. The patient's diagnosis included alcohol dependence disorder, cocaine use disorder, substance induced mood disorder and bipolar disorder without psychosis.

B. The Psychiatric Evaluation dated 8/7/2022 indicated, " ...The patient currently endorses suicidal ideation, with plan to walk in traffic ...The patient endorses withdrawal symptoms of anxiety ..."

C. The Treatment Plan dated 8/6/2022 indicated:
-Problem: Suicidal thoughts, Goal: I will be free from suicidal thoughts and contract for safety while in the unit, Objective: I will take all medications as prescribed; I will attend therapy sessions either as a group or individually; I will think of one coping skill each day to help with my thoughts and feelings, Intervention: Physicians will prescribe appropriate mood stabilizing medication; Nurse will administer medications as ordered; Therapy will hold daily therapy sessions
-Problem: I want to discharge to a safe place and not be homeless, Objective: I will find a safe place to live prior to discharge; I will follow up with outpatient services as recommended by my doctor, I will identify ways to get my medication upon discharge, Intervention: CM will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in finding resources to help with medication acquisition

-The treatment plan did not identify all the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

4. On 8/10/2022 at 9:40 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Vice President of Quality (VPQ). The VPQ confirmed there was no documentary evidence in patients' medical records of specific treatment programs or services provided or offered to the patients. The VP confirmed there was no documentary evidence of treatment notes to indicate provision of and the patients' response to specific treatment program.

5. On 8/10/2022 at 11:50 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Risk Manager (RM).
A. The RM stated, "There should be note whether the patient attended (therapy) or not." The RM stated the patients' medical records "Needs to have documentation of patient participation, or at least attempts to encourage to attend groups."

B. The RM stated Patient #4 and Patient #5 should have had at least a treatment note from the OT Occupational Therapist (OT) on 8/8/2022. The RM stated the patients' record did not have any notes from the Occupational Therapist (OT) who conducted group occupational therapy on Mondays, Wednesdays, and Fridays because the OT was vacation for three weeks. The RM stated she was not aware of this until today and was not aware if anyone was covering for the OT.

C. The RM stated the Director of Inpatient Clinical Services oversees the implementation of Clinical Group Schedule. The RM stated the Director of Inpatient Clinical Services position has been vacant for at least four weeks.

5. On 8/10/2022 at 12:30 p.m. the NM was interviewed. The NM stated she conducted an audit on treatment plans initiated in April, May and June 2022 but had stopped.

6. On 8/10/2022 at 12:40 p.m. The Hospital A (Psych) Clinical Group Schedule and (Detox) Clinical Group Schedule for August 1 - 15, 2022 was reviewed with the NM.

A. The NM stated the OT who conducted the Occupational Therapy has been on vacation and she was not aware if anyone was covering and if the Occupational Therapy indicated in the calendar has been conducted since. The NM stated the clinicians who were supposed to conduct the groups and activities have not been documenting in the patients' records.

B. The NM stated the Hospital A (Psych) Clinical schedule was the daily schedule of activities for all the patients in the psychiatric unit. The schedule indicated:
-Monday
10 AM-11 AM Occupational Therapy
11 AM-12 PM Elective Activity
1 PM - 2 PM Group Therapy
3 PM - 4 PM Group Therapy

-Tuesday
11 AM-12 PM Group Therapy
1 PM - 2 PM Elective Activity
3 PM - 4 PM Group Therapy

-Wednesday
10 AM-11 AM Occupational Therapy
11 AM-12 PM Group Therapy
1 PM - 2 PM Group Therapy

-Thursday
11 AM-12 PM Group Therapy
1 PM - 2 PM Group Therapy
3 PM - 4 PM Elective Activity

-Friday
10 AM-11 AM Occupational Therapy
11 AM-12 PM Group Therapy
1 PM - 2 PM Elective Activity
3 PM - 4 PM Group Therapy

-Saturday and Sunday
11 AM-12 PM Group Therapy

C. The NM stated the Detox Clinical Group schedule was the daily schedule of activities for all the patients in the detox unit. The schedule indicated:

-Monday
10 AM-11 AM Group Therapy
11 AM-12 PM Group Therapy
1 PM - 2 PM Elective Activity
3 PM - 4 PM Group Therapy

-Tuesday
10 AM-11 AM Group Therapy
11 AM-12 PM Group Therapy
1 PM - 2 PM Elective Activity

-Wednesday
10 AM-11 AM Group Therapy
1 PM - 2 PM Elective Activity
3 PM - 4 PM Group Therapy

-Thursday
10 AM-11 AM Group Therapy
11 AM-12 PM Elective Activity
1 PM - 2 PM Group Therapy
3 PM - 4 PM Elective Activity

-Friday
10 AM-11 AM Group Therapy
1 PM - 2 PM Elective Activity
3 PM - 4 PM Group Therapy

-Saturday and Sunday
1 PM - 2 PM Group Therapy

D. The specific purpose and focus of the therapies and activities were not indicated in the schedules. There was no documentary evidence of the specific descriptions of the of the therapies and activities indicated in the schedules.

E. Furthermore, there was no documentary evidence that the therapies and activities from August 1 were conducted. There was no documentary evidence of names of patients who attended the therapies and activities from August 1.

7. On 8/11/2022 at 11:20 a.m., the Director of Clinical Education (DCE) was interviewed.

A. The DCE stated hospital patients should have 5 hours of group and therapeutic activities combined in a day and the specific treatment group and activities should be in the patient's treatment plan. The DCE stated "refusal, attendance and non-attendance should be documented in the patient's record."

B. The DCE stated the Director of Inpatient Clinical Services creates the calendar at least monthly, assigns the clinical staff who will conduct the group or activity and oversees the implementation of the clinical services.

C. The DCE stated since position has been the clinical interns have not been trained on documenting in the psychiatric hospital's electronic medical records software. The DCE stated the clinical interns have been documenting their treatment notes "In word" in their laptops. The DCE stated the other members of the interdisciplinary team did not have access to the treatment notes from counseling, groups and other activities conducted by the clinical interns because the notes were "in their laptops." The DCE stated it was around mid-July this year when the new group of clinical interns started.

Based on staff interview, document review and medical record review it was determined the facility failed to maintain medical records for three (Patient # 3, #4, and #5) out of ten sampled patients. The medical records did not permit determination of the degree and intensity of the treatment provided to the patients who were furnished services in the institution.

Review of the treatment plan for two patients (Patient #3 and #4) of ten sampled patients, failed to show the patient had an individualized, comprehensive treatment plan based on an inventory of the patient's strengths and disabilities. Refer to A1640.

Review of the treatment plan for three patients (Patient #3, #4, and #5) of ten sampled patients, failed to demonstrate specific treatments utilized. Refer to A1643.

Review of treatments received by three patients (Patient #3, #4, and #5) of ten sampled patients, failed to reveal, in such a way to assure that all active therapeutic efforts were provided. The clinical interns failed to document treatment notes in the patients' medical records. Refer to A1650.

Review of the treatment notes for three patients (Patient #3, #4, and #5) of ten sampled patients, failed to reveal, significant clinical staff involved in the provision of active patient treatment modalities, were documented in the patient's medical record. Refer to A1655.

Based on staff interviews, medical record reviews, and facility policy and procedures it was determined the treatment plans failed to demonstrate an individualized, comprehensive plan, based on an inventory of the patient's strengths and disabilities, for two patients (Patient #3 and #4) out of ten sampled patients.

Findings included:

1. Review of the MR (medical record) for Patient #3 with the Hospital Nurse Manager (NM) indicated the following:

A. The Patient was a 40-year-old woman who was admitted on 8/5/2022 to the psychiatric hospital on an involuntary basis for "bizarre behavior and voicing homicidal ideations towards her neighbors outside her home". The patient was discharge from the psychiatric hospital on 8/8/2022. The patient's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) with psychotic features and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

B. The Psychiatric Evaluation dated 8/5/2022 indicated, " ...Her behaviors towards them (neighbors) have resulted in multiple encounters with the police. At one time she exposed her genitalia to her next-door neighbor ...Most recently, she got in a verbal confrontation with a neighbor and at one point threatened to stab him with a knife ..." The evaluation further indicated " ...The patient consistently exhibits paranoid delusions, splitting, labile affect, flight of ideas ..."

C. The Treatment Plan dated 8/5/2022 indicated:

-Problem: Adjustment disorder, Goal: "I am not suicidal. I shouldn't be here", Objective: "I need to be released", Interventions: MD (doctor) will evaluate client and determine what medications will help client, RN (registered nurse) will educate client on medications prescribed, client will report any side effects of medication taken.

-Problem: Pain, Goal "After the morphine wears off I'll be in constant pain", Objective: "I take medical marijuana for the pain, but I've been out for 2 weeks", Intervention: Pain assessment will be performed as ordered for client; MD will prescribe medications to help client with the pain; Client will have pain 0-4 on a scale of 0-10.

-Problem: Discharge planning issues. The problem did not have a goal. The problem did not have any objectives nor interventions.

-The area "Strengths and Challenges" was blank.

2. Review of the MR for Patient #4 with the NM indicated the following:

A. The patient was a 53-year-old male admitted on 8/7/2022 to the psychiatric hospital on an involuntary basis for "homicidal ideation". The patient's diagnosis included persistent complex bereavement disorder with psychotic features, PTSD and alcohol abuse.

B. The Psychiatric Evaluation dated 8/8/2022 indicated, " ...Patient states he began binge drinking on Friday and drank continually through the weekend ...The patient stated to the police that he plans to eventually murder his brother-in-law as an act of revenge and consuming his remains..." The evaluation further indicated "Plan ...Order individual therapy ...Encourage participation in group therapy sessions as inpatient, provide therapeutic milieu ..."

C. The Treatment Plan dated 8/7/2022 indicated:
-Problem: ETOH (alcohol) dependence, Goal: I will stay away from alcohol after DC, Objective: I will discuss the circumstances of my addiction (PTSD); I will report any s/s of withdrawal to the nurse, Intervention: Nurse will assess patient daily for s/s (signs and symptoms) of alcohol withdrawal; BHT (Behavioral Health Technician) will encourage client to attend therapy and all educational groups offered.

-Problem: Post traumatic stress disorder, Goal: I will be free of PTSD symptoms after DC, Objective: I will participate in therapies to know how to manage my PTSD symptoms such as flashbacks, insomnia, mood instabilities, among others; MD will prescribe me medication to help me with the symptoms combining with psychotherapies, Intervention: Nurse will administer medication as prescribed by MD; MD will prescribe medication to help with symptoms of PTSD.
-Problem: Discharge planning issues, Goal: I want to live somewhere I am supported, Objective: I will establish an outside support system prior to discharge; I will follow up with outpatient services as recommended by my doctor; I will discharge to a safe environment, Intervention: CM (case manager) will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in identifying personal and community support x 1 and as needed x 7 days.

-The area "Strengths and Challenges" was blank.

3. On 8/10/2022 at 12:30 p.m. the NM was interviewed. The NM stated she conducted an audit on treatment plans initiated in April, May and June 2022 but had stopped.

4. On 8/11/2022 @ 10:30 a.m. the Interim Hospital Administrator (Administrator) was interviewed. The Administrator stated they planned on hiring one person to do quality audits on treatment plans.

5. On 8/10/2022 at 2:40 p.m., the psychiatric hospital's policy and procedure 13.14. FL titled, "Clinical and Administrative Policies and Procedures, Clinical Operations, Intensive Inpatient Treatment Clinical Guidelines" last reviewed 6/3/2021 was reviewed with the RM. The RM confirmed the policy and procedure applied to all hospital patients and was current for the hospital. The policy and procedure indicated: "Treatment Plan and Treatment Plan Reviews. Each client will be included in the development of the treatment plan. a. The treatment plan shall include goals and related measurable behavioral objectives to be achieved by the client, the tasks involved in achieving those objectives, the type and frequency of services to be provided, and the expected dates of completion .... The treatment plan will be completed within three (3) calendar days of placement ..."

Based on staff interview, medical record review, and review of facility policy and procedure it was determined the treatment plan failed to indicate specific treatments utilized for three patients (Patient #3, #4, and #5) out of ten sampled patients.

Findings included:

1. Review of the MR (medical record) for Patient #3 with the Hospital Nurse Manager (NM) indicated the following:

A. The Patient was a 40-year-old woman who was admitted on 8/5/2022 to the psychiatric hospital on an involuntary basis for "bizarre behavior and voicing homicidal ideations towards her neighbors outside her home". The patient was discharge from the psychiatric hospital on 8/8/2022. The patient's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) with psychotic features and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

B. The Psychiatric Evaluation dated 8/5/2022 indicated, " ...Her behaviors towards them (neighbors) have resulted in multiple encounters with the police. At one time she exposed her genitalia to her next-door neighbor ...Most recently, she got in a verbal confrontation with a neighbor and at one point threatened to stab him with a knife ..." The evaluation further indicated " ...The patient consistently exhibits paranoid delusions, splitting, labile affect, flight of ideas ..."

C. The Treatment Plan dated 8/5/2022 indicated:

-Problem: Adjustment disorder, Goal: "I am not suicidal. I shouldn't be here", Objective: "I need to be released", Interventions: MD (doctor) will evaluate client and determine what medications will help client, RN (registered nurse) will educate client on medications prescribed, client will report any side effects of medication taken.

-Problem: Pain, Goal "After the morphine wears off I'll be in constant pain", Objective: "I take medical marijuana for the pain, but I've been out for 2 weeks", Intervention: Pain assessment will be performed as ordered for client; MD will prescribe medications to help client with the pain; Client will have pain 0-4 on a scale of 0-10.

-Problem: Discharge planning issues. The problem did not have a goal. The problem did not have any objectives nor interventions.

-The treatment plan did not identify the patient's psychiatric therapeutic needs and specific treatment programs to address them.

2. Review of the MR for Patient #4 with the NM indicated the following:

A. The patient was a 53 year-old male admitted on 8/7/2022 to the psychiatric hospital on an involuntary basis for "homicidal ideation". The patient's diagnosis included persistent complex bereavement disorder with psychotic features, PTSD and alcohol abuse.

B. The Psychiatric Evaluation dated 8/8/2022 indicated, " ...Patient states he began binge drinking on Friday and drank continually through the weekend ...The patient stated to the police that he plans to eventually murder his brother-in-law as an act of revenge and consuming his remains..." The evaluation further indicated "Plan ...Order individual therapy ...Encourage participation in group therapy sessions as inpatient, provide therapeutic milieu ..."

C. The Treatment Plan dated 8/7/2022 indicated:
-Problem: ETOH (alcohol) dependence, Goal: I will stay away from alcohol after DC, Objective: I will discuss the circumstances of my addiction (PTSD); I will report any s/s of withdrawal to the nurse, Intervention: Nurse will assess patient daily for s/s (signs and symptoms) of alcohol withdrawal; BHT will encourage client to attend therapy and all educational groups offered.

-Problem: Post traumatic stress disorder, Goal: I will be free of PTSD symptoms after DC, Objective: I will participate in therapies to know how to manage my PTSD symptoms such as flashbacks, insomnia, mood instabilities, among others; MD will prescribe me medication to help me with the symptoms combining with psychotherapies, Intervention: Nurse will administer medication as prescribed by MD; MD will prescribe medication to help with symptoms of PTSD.
-Problem: Discharge planning issues, Goal: I want to live somewhere I am supported, Objective: I will establish an outside support system prior to discharge; I will follow up with outpatient services as recommended by my doctor; I will discharge to a safe environment, Intervention: CM (case manager) will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in identifying personal and community support x 1 and as needed x 7 days.

-The treatment plan did not indicate specific treatment programs to address the patient's psychiatric therapeutic needs.

3. Review of the MR for Patient #5 with the NM indicated the following:

A. The patient was a 61 year-old male admitted on 8/6/2022 to the psychiatric hospital on an involuntary basis for suicidal ideation. The patient's diagnosis included alcohol dependence disorder, cocaine use disorder, substance induced mood disorder and bipolar disorder without psychosis.

B. The Psychiatric Evaluation dated 8/7/2022 indicated, " ...The patient currently endorses suicidal ideation, with plan to walk in traffic ...The patient endorses withdrawal symptoms of anxiety ..."

C. The Treatment Plan dated 8/6/2022 indicated:
-Problem: Suicidal thoughts, Goal: I will be free from suicidal thoughts and contract for safety while in the unit, Objective: I will take all medications as prescribed; I will attend therapy sessions either as a group or individually; I will think of one coping skill each day to help with my thoughts and feelings, Intervention: Physicians will prescribe appropriate mood stabilizing medication; Nurse will administer medications as ordered; Therapy will hold daily therapy sessions
-Problem: I want to discharge to a safe place and not be homeless, Objective: I will find a safe place to live prior to discharge; I will follow up with outpatient services as recommended by my doctor, I will identify ways to get my medication upon discharge, Intervention: CM will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in finding resources to help with medication acquisition

-The treatment plan did not identify all the patient's psychiatric therapeutic needs and specific treatment programs to address them.

4. On 8/10/2022 at 12:30 p.m. the NM was interviewed. The NM stated she conducted an audit on treatment plans initiated in April, May and June 2022 but had stopped.

5. On 8/10/2022 at 9:40 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Vice President of Quality (VPQ). The VPQ confirmed there was no documentary evidence in patients' treatment plans of specific treatment programs or services to be provided to the patients.

6. On 8/11/2022 @ 10:30 a.m. the Interim Hospital Administrator (Administrator) was interviewed. The Administrator stated they planned on hiring one person to do quality audits on treatment plans.

7. On 8/10/2022 at 2:40 p.m., the psychiatric hospital's policy and procedure 13.14. FL titled, "Clinical and Administrative Policies and Procedures, Clinical Operations, Intensive Inpatient Treatment Clinical Guidelines" last reviewed 6/3/2021 was reviewed with the RM. The RM stated confirmed the policy and procedure applied to all hospital patients and was current for the hospital. The policy and procedure indicated: "Treatment Plan and Treatment Plan Reviews. Each client will be included in the development of the treatment plan. a. The treatment plan shall include goals and related measurable behavioral objectives to be achieved by the client, the tasks involved in achieving those objectives, the type and frequency of services to be provided, and the expected dates of completion ...e. The treatment plan will be completed within three (3) calendar days of placement ..."

Based on staff interviews, medical record reviews, and review of facility policy and procedures, it was determined the facility failed to ensure clinical interns documented in the patients medical record; and failed to document the treatments received by patients in such a way to assure that all active therapeutic efforts were included for three (Patient #3, #4 and #5) out of ten sampled patients.

Findings included:

1. Review of the MR (medical record) for Patient #3 with the Hospital Nurse Manager (NM) indicated the following:

A. The Patient was a 40-year-old woman who was admitted on 8/5/2022 to the psychiatric hospital on an involuntary basis for "bizarre behavior and voicing homicidal ideations towards her neighbors outside her home". The patient was discharge from the psychiatric hospital on 8/8/2022. The patient's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) with psychotic features and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

B. The Psychiatric Evaluation dated 8/5/2022 indicated, " ...Her behaviors towards them (neighbors) have resulted in multiple encounters with the police. At one time she exposed her genitalia to her next-door neighbor ...Most recently, she got in a verbal confrontation with a neighbor and at one point threatened to stab him with a knife ..." The evaluation further indicated " ...The patient consistently exhibits paranoid delusions, splitting, labile affect, flight of ideas ..."

C. The Treatment Plan dated 8/5/2022 indicated:

-Problem: Adjustment disorder, Goal: "I am not suicidal. I shouldn't be here", Objective: "I need to be released", Interventions: MD (doctor) will evaluate client and determine what medications will help client, RN (registered nurse) will educate client on medications prescribed, client will report any side effects of medication taken.

-Problem: Pain, Goal "After the morphine wears off I'll be in constant pain", Objective: "I take medical marijuana for the pain, but I've been out for 2 weeks", Intervention: Pain assessment will be performed as ordered for client; MD will prescribe medications to help client with the pain; Client will have pain 0-4 on a scale of 0-10.

-Problem: Discharge planning issues. The problem did not have a goal. The problem did not have any objectives nor interventions.

-The treatment plan did not identify the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #3's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

2. Review of the MR for Patient #4 with the NM indicated the following:

A. The patient was a 53 year-old male admitted on 8/7/2022 to the psychiatric hospital on an involuntary basis for "homicidal ideation". The patient's diagnosis included persistent complex bereavement disorder with psychotic features, PTSD and alcohol abuse.

B. The Psychiatric Evaluation dated 8/8/2022 indicated, " ...Patient states he began binge drinking on Friday and drank continually through the weekend ...The patient stated to the police that he plans to eventually murder his brother-in-law as an act of revenge and consuming his remains..." The evaluation further indicated "Plan ...Order individual therapy ...Encourage participation in group therapy sessions as inpatient, provide therapeutic milieu ..."

C. The Treatment Plan dated 8/7/2022 indicated:
-Problem: ETOH (alcohol) dependence, Goal: I will stay away from alcohol after DC, Objective: I will discuss the circumstances of my addiction (PTSD); I will report any s/s of withdrawal to the nurse, Intervention: Nurse will assess patient daily for s/s (signs and symptoms) of alcohol withdrawal; BHT will encourage client to attend therapy and all educational groups offered.

-Problem: Post traumatic stress disorder, Goal: I will be free of PTSD symptoms after DC, Objective: I will participate in therapies to know how to manage my PTSD symptoms such as flashbacks, insomnia, mood instabilities, among others; MD will prescribe me medication to help me with the symptoms combining with psychotherapies, Intervention: Nurse will administer medication as prescribed by MD; MD will prescribe medication to help with symptoms of PTSD.
-Problem: Discharge planning issues, Goal: I want to live somewhere I am supported, Objective: I will establish an outside support system prior to discharge; I will follow up with outpatient services as recommended by my doctor; I will discharge to a safe environment, Intervention: CM (case manager) will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in identifying personal and community support x 1 and as needed x 7 days.

-The treatment plan did not indicate specific treatment programs to address the patient's psychiatric therapeutic needs.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

3. Review of the MR for Patient # 5 with the NM indicated the following:

A. The patient was a 61 year-old male admitted on 8/6/2022 to the psychiatric hospital on an involuntary basis for suicidal ideation. The patient's diagnosis included alcohol dependence disorder, cocaine use disorder, substance induced mood disorder and bipolar disorder without psychosis.

B. The Psychiatric Evaluation dated 8/7/2022 indicated, " ...The patient currently endorses suicidal ideation, with plan to walk in traffic ...The patient endorses withdrawal symptoms of anxiety ..."

C. The Treatment Plan dated 8/6/2022 indicated:
-Problem: Suicidal thoughts, Goal: I will be free from suicidal thoughts and contract for safety while in the unit, Objective: I will take all medications as prescribed; I will attend therapy sessions either as a group or individually; I will think of one coping skill each day to help with my thoughts and feelings, Intervention: Physicians will prescribe appropriate mood stabilizing medication; Nurse will administer medications as ordered; Therapy will hold daily therapy sessions
-Problem: I want to discharge to a safe place and not be homeless, Objective: I will find a safe place to live prior to discharge; I will follow up with outpatient services as recommended by my doctor, I will identify ways to get my medication upon discharge, Intervention: CM will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in finding resources to help with medication acquisition

-The treatment plan did not identify all the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #5's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

4. On 8/10/2022 at 9:40 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Vice President of Quality (VPQ). The VPQ confirmed there was no documentary evidence in patients' medical records of specific treatment programs or services provided or offered to the patients. The VP confirmed there was no documentary evidence of treatment notes to indicate provision of and the patients' response to specific treatment program.

5. On 8/10/2022 at 11:50 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Risk Manager (RM).
A. The RM stated, "There should be note whether the patient attended (therapy) or not." The RM stated the patients' medical records "Needs to have documentation of patient participation, or at least attempts to encourage to attend groups."

B. The RM stated Patient #4 and Patient #5 should have had at least a treatment note from the OT Occupational Therapist (OT) on 8/8/2022. The RM stated the patients' record did not have any notes from the Occupational Therapist (OT) who conducted group occupational therapy on Mondays, Wednesdays, and Fridays because the OT was vacation for three weeks. The RM stated she was not aware of this until today and was not aware if anyone was covering for the OT.

6. On 8/11/2022 at 11:20 a.m., the Director of Clinical Education (DCE) was interviewed.

A. The DCE stated hospital patients should have 5 hours of group and therapeutic activities combined in a day and the specific treatment group and activities should be in the patient's treatment plan. The DCE stated "refusal, attendance and non-attendance should be documented in the patient's record."

B. The DCE stated the Director of Inpatient Clinical Services created the calendar at least monthly, assigned the clinical staff who will conduct the group or activity and oversaw the implementation of the clinical services program.

C. The DCE stated since position of Director of Inpatient Clinical Service has been vacant the interns have not been trained on documenting in the psychiatric hospital's electronic medical records software. The DCE stated the clinical interns have been documenting their treatment notes "In word" in their laptops. The DCE stated the other member of the interdisciplinary team did not have access to the treatment notes from counseling, groups and other activities conducted by the clinical interns because the notes were "in their laptops" and not in the patients' medical records. The DCE stated it was around mid-July this year when the new group of clinical interns started.

7. On 8/10/2022 at 2:40 p.m., the psychiatric hospital's policy and procedure 13.14. FL titled, "Clinical and Administrative Policies and Procedures, Clinical Operations, Intensive Inpatient Treatment Clinical Guidelines" last reviewed 6/3/2021 was reviewed with the RM. The RM stated confirmed the policy and procedure applied to all hospital patients and was current for the hospital. The policy and procedure indicated:

A. "Purpose: Intensive Inpatient Treatment include a planned regimen of evaluation, observation, medical monitoring, and clinical services delivered through an interdisciplinary team 24 hours-per-day, 7 days per week in a hospital setting. Intensive Inpatient Treatment is appropriate for individuals whose acute biomedical, behavioral, cognitive, and emotional problems are severe enough to require primary medical and nursing care."

B. "Procedure: A. Standard Services provided include but not limited to the following: a. Individual counseling, b. Group counseling, c. Counseling with the client's family and/or support system, d. Substance abuse education, e. Education or information on the client's specific mental health and/or medical issues, f. Life skills training, g. Expressive therapies, h. Employment and /or educational support services, i. Mental health services B. Specialized services include but not limited to the following: a. Daily clinical services by an interdisciplinary team designed to stabilize acute substance use and other psychiatric symptoms b. Co-occurring enhanced services utilizing best practices c. Monitoring the individual's compliance in taking prescription medication on a regular basis."

C. "Hours of Services: a. Clients in the Intensive Treatment program will receive at least 14 hours of counseling and 20 hours of other structured services per week. If the client requires fewer hours each week it must be documented in the clinical record."
D. "Progress notes will be entered in the clinical record documenting the client's progress or lack of progress towards meeting treatment plan goals and objectives."

Based on staff interviews, medical record reviews, and review of facility policy and procedures, it was determined the facility failed to ensure the treatment notes, of significant clinical staff involved in the provision of active treatment modalities, were documented in the patient's medical record for three (Patient #3, #4, and #5) of ten sampled patients.

Findings included:

1. Review of the MR (medical record) for Patient #3 with the Hospital Nurse Manager (NM) indicated the following:

A. The Patient was a 40-year-old woman who was admitted on 8/5/2022 to the psychiatric hospital on an involuntary basis for "bizarre behavior and voicing homicidal ideations towards her neighbors outside her home". The patient was discharge from the psychiatric hospital on 8/8/2022. The patient's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) with psychotic features and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

B. The Psychiatric Evaluation dated 8/5/2022 indicated, " ...Her behaviors towards them (neighbors) have resulted in multiple encounters with the police. At one time she exposed her genitalia to her next-door neighbor ...Most recently, she got in a verbal confrontation with a neighbor and at one point threatened to stab him with a knife ..." The evaluation further indicated " ...The patient consistently exhibits paranoid delusions, splitting, labile affect, flight of ideas ..."

C. The Treatment Plan dated 8/5/2022 indicated:

-Problem: Adjustment disorder, Goal: "I am not suicidal. I shouldn't be here", Objective: "I need to be released", Interventions: MD (doctor) will evaluate client and determine what medications will help client, RN (registered nurse) will educate client on medications prescribed, client will report any side effects of medication taken.

-Problem: Pain, Goal "After the morphine wears off, I'll be in constant pain", Objective: "I take medical marijuana for the pain, but I've been out for 2 weeks", Intervention: Pain assessment will be performed as ordered for client; MD will prescribe medications to help client with the pain; Client will have pain 0-4 on a scale of 0-10.

-Problem: Discharge planning issues. The problem did not have a goal. The problem did not have any objectives nor interventions.

-The treatment plan did not identify the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

2. Review of the MR for Patient #4 with the NM indicated the following:

A. The patient was a 53-year-old male admitted on 8/7/2022 to the psychiatric hospital on an involuntary basis for "homicidal ideation". The patient's diagnosis included persistent complex bereavement disorder with psychotic features, PTSD, and alcohol abuse.

B. The Psychiatric Evaluation dated 8/8/2022 indicated, " ...Patient states he began binge drinking on Friday and drank continually through the weekend ...The patient stated to the police that he plans to eventually murder his brother-in-law as an act of revenge and consuming his remains..." The evaluation further indicated "Plan ...Order individual therapy ...Encourage participation in group therapy sessions as inpatient, provide therapeutic milieu ..."

C. The Treatment Plan dated 8/7/2022 indicated:
-Problem: ETOH (alcohol) dependence, Goal: I will stay away from alcohol after DC (discharge), Objective: I will discuss the circumstances of my addiction (PTSD); I will report any s/s of withdrawal to the nurse, Intervention: Nurse will assess patient daily for s/s (signs and symptoms) of alcohol withdrawal; BHT (Behavioral Health Technician) will encourage client to attend therapy and all educational groups offered.

-Problem: Post traumatic stress disorder, Goal: I will be free of PTSD symptoms after DC, Objective: I will participate in therapies to know how to manage my PTSD symptoms such as flashbacks, insomnia, mood instabilities, among others; MD will prescribe me medication to help me with the symptoms combining with psychotherapies, Intervention: Nurse will administer medication as prescribed by MD; MD will prescribe medication to help with symptoms of PTSD.
-Problem: Discharge planning issues, Goal: I want to live somewhere I am supported, Objective: I will establish an outside support system prior to discharge; I will follow up with outpatient services as recommended by my doctor; I will discharge to a safe environment, Intervention: CM (case manager) will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in identifying personal and community support x 1 and as needed x 7 days.

-The treatment plan did not indicate specific treatment programs to address the patient's psychiatric therapeutic needs.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

3. Review of the MR for Patient # 5 with the NM indicated the following:

A. The patient was a 61-year-old male admitted on 8/6/2022 to the psychiatric hospital on an involuntary basis for suicidal ideation. The patient's diagnosis included alcohol dependence disorder, cocaine use disorder, substance induced mood disorder and bipolar disorder without psychosis.

B. The Psychiatric Evaluation dated 8/7/2022 indicated, " ...The patient currently endorses suicidal ideation, with plan to walk in traffic ...The patient endorses withdrawal symptoms of anxiety ..."

C. The Treatment Plan dated 8/6/2022 indicated:
-Problem: Suicidal thoughts, Goal: I will be free from suicidal thoughts and contract for safety while in the unit, Objective: I will take all medications as prescribed; I will attend therapy sessions either as a group or individually; I will think of one coping skill each day to help with my thoughts and feelings, Intervention: Physicians will prescribe appropriate mood stabilizing medication; Nurse will administer medications as ordered; Therapy will hold daily therapy sessions
-Problem: I want to discharge to a safe place and not be homeless, Objective: I will find a safe place to live prior to discharge; I will follow up with outpatient services as recommended by my doctor, I will identify ways to get my medication upon discharge, Intervention: CM will provide aftercare appointment; CM to provide client with resources for housing; CM will assist in finding resources to help with medication acquisition

-The treatment plan did not identify all the patient's psychiatric therapeutic needs and specific treatment programs to address them.

D. Further review of the MR did not indicate documentary evidence of specific treatment programs or services provided and or offered to the patient. There was no documentary evidence in Patient #4's MR to determine the degree and intensity of treatments provided to the patient or the patient's response to them.

4. On 8/10/2022 at 9:40 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Vice President of Quality (VPQ). The VPQ confirmed there was no documentary evidence in patients' medical records of specific treatment programs or services provided or offered to the patients. The VP confirmed there was no documentary evidence of treatment notes to indicate provision of and the patients' response to specific treatment program.

5. On 8/10/2022 at 11:50 a.m. the MR of Patient #3, #4 and #5 were reviewed with the Risk Manager (RM).
A. The RM stated, "There should be a note whether the patient attended (therapy) or not." The RM stated the patients' medical records, "Needs to have documentation of patient participation, or at least attempts to encourage to attend groups."

B. The RM stated Patient #4 and Patient #5 should have had at least a treatment note from the OT (Occupational Therapist) on 8/8/2022. The RM stated the patients' record did not have any notes from the Occupational Therapist (OT) who conducted group occupational therapy on Mondays, Wednesdays, and Fridays because the OT was vacation for three weeks. The RM stated she was not aware of this until today and was not aware if anyone was covering for the OT.

6. On 8/11/2022 at 11:20 a.m., the Director of Clinical Education (DCE) was interviewed.

A. The DCE stated hospital patients should have 5 hours of group and therapeutic activities combined in a day and the specific treatment group and activities should be in the patient's treatment plan. The DCE stated "refusal, attendance and non-attendance should be documented in the patient's record."

B. The DCE stated the Director of Inpatient Clinical Services created the calendar at least monthly, assigned the clinical staff who will conduct the group or activity and oversaw the implementation of the clinical services program.

C. The DCE stated since the position of Director of Inpatient Clinical Service has been vacant the interns have not been trained on documenting in the psychiatric hospital's electronic medical records software. The DCE stated the clinical interns have been documenting their treatment notes "In word" on their laptops. The DCE stated the other members of the interdisciplinary team did not have access to the treatment notes from counseling, groups and other activities conducted by the clinical interns because the notes were "in their laptops" and not in the patients' medical records. The DCE stated it was around mid-July this year when the new group of clinical interns started.

7. On 8/10/2022 at 2:40 p.m., the psychiatric hospital's policy and procedure 13.14. FL titled, "Clinical and Administrative Policies and Procedures, Clinical Operations, Intensive Inpatient Treatment Clinical Guidelines" last reviewed 6/3/2021 was reviewed with the RM. The RM stated confirmed the policy and procedure applied to all hospital patients and was current for the hospital. The policy and procedure indicated:

A. "Purpose: Intensive Inpatient Treatment include a planned regimen of evaluation, observation, medical monitoring, and clinical services delivered through an interdisciplinary team 24 hours-per-day, 7 days per week in a hospital setting. Intensive Inpatient Treatment is appropriate for individuals whose acute biomedical, behavioral, cognitive, and emotional problems are severe enough to require primary medical and nursing care."

B. "Procedure: A. Standard Services provided include but not limited to the following: a. Individual counseling, b. Group counseling, c. Counseling with the client's family and/or support system, d. Substance abuse education, e. Education or information on the client's specific mental health and/or medical issues, f. Life skills training, g. Expressive therapies, h. Employment and /or educational support services, i. Mental health services B. Specialized services include but not limited to the following: a. Daily clinical services by an interdisciplinary team designed to stabilize acute substance use and other psychiatric symptoms b. Co-occurring enhanced services utilizing best practices c. Monitoring the individual's compliance in taking prescription medication on a regular basis."

C. "Hours of Services: a. Clients in the Intensive Treatment program will receive at least 14 hours of counseling and 20 hours of other structured services per week. If the client requires fewer hours each week it must be documented in the clinical record."

D. "Progress notes will be entered in the clinical record documenting the client's progress or lack of progress towards meeting treatment plan goals and objectives."