HospitalInspections.org

A Life Safety Code Recertification Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

At this Life Safety Code survey, Northeastern Center was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This one story facility with an atrium was determined to be of Type V (000) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors and patients rooms. The facility has a capacity of 16 and had a census of 15 at the time of this survey.

Based on document review, observation and interview, the hospital failed to maintain its environment of care in a manner to ensure the safety of patients at risk for self-harm in 16 of 16 inpatient rooms at the facility (see tag A701), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA (see tag K 341), the facility failed to maintain 1 of 1 sprinkler system (see tag K353), the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier (see tag K372), the facility failed to ensure 2 of 2 candles were maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met (see tag K753), the facility failed to enforce 1 of 1 policy for the use of portable space heaters (see tag K781), and the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring (see tag K920).

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

Based on document review, observation and interview, the hospital failed to maintain its environment of care in a manner to ensure the safety of patients at risk for self-harm for 16 of 16 inpatient rooms at the facility, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants, and the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect all occupants.

Findings include:

1. Review of the policy/procedure Inpatient Program Description (reviewed 1-18) indicated the following: "To identify appropriate admissions... the potential patient must show a high risk of self-harm..."

2. Review of the policy/procedure Risk Management (reviewed 7-17) indicated the following: "Building Inspections shall occur periodically to assess safety and risk."

3. Review of the 1-31-18 Quarterly Building Inspections Form and Report for the inpatient unit conducted by the maintenance staff A11 lacked documentation indicating to observe for features that allowed for securing clothing or fabric material to fixtures and/or equipment to enable self-asphyxiation by a patient at risk for self-harm.

4. During a tour on 2-28-18 at 1200 hours, in the company of the Quality Improvement Director, staff A2, the following hazardous condition were observed in 15 patient rooms; a blade-type door handle positioned in an upward direction on the inside of each bathroom door.

5. During a tour on 2-28-18 at 1205 hours, in the company of the Quality Improvement Director, staff A2, the following hazardous condition were observed in patient room 110; a blade-type door handle positioned in an upward direction on the outside of the bathroom door.

6. On 2-28-18 at 1210 hours, Quality Improvement Director, staff A2 confirmed the secluded door handles represented a critical safety hazard by creating a secure attachment point for attempting suicide by ligature resulting in death by asphyxiation.

7. Based on record review with the Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly control valves, weekly dry system gauge and monthly wet system gauge inspection. Based on interview at the time of record review, the Register Nurse #1 and the Maintenance Director acknowledged the lack of documentation.

8. Based on observations with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:33 p.m. then again at 12:36 p.m., a half inch gap around wires in the smoke barrier near resident room 101. Then again, a quarter inch gap inside conduit in the smoke barrier near resident room 201. Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 2 of 2 candles were maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff only, the facility failed to enforce 1 of 1 policy for the use of portable space heaters in accordance with 19.7.8. This deficient practice could affect staff only, and the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

1. Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:23 p.m., two separate candles with wicks was discovered in the Assistant Director of Nursing office. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director confirmed a wick was in each candle.

2. Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:22 a.m., two separate space heaters were discovered in the business office. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director acknowledged the space heaters were a violation of the facility's policy.

3. Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:13 p.m. then again at 12:22 p.m., an extension cord was powering a fan in the Case Manager's office. Then again, a surge protector was powering a refrigerator in the Business office. Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged each aforementioned and removed the extension cord upon discovery.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 between 11:36 a.m. and 12:56 p.m., the following smoke detectors were discovered fifteen inches near HVAC vents:
a) Main Entrance
b) by room 205
c) by room 201
d) Receiving room
Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged the smoke detectors were located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

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

I. Ensure Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) that reflect the anticipated role of the social work staff in treatment intervention and discharge planning. This failure resulted in the treatment team not having information about what efforts the social service staff has determined necessary during hospitalization of the patient and afterwards. (Refer to B108)

II. Ensure Medical History and Physical Examination for eight (8) of (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included a neurological examination of cranial nerves II through XII was documented. This failure to record detailed neurological findings makes it difficult to ascertain progression/worsening of patient's condition on subsequent re-examination. (Refer to B109)

III. Ensure Psychiatric Evaluation called (Evaluation & Management Progress Note; New Patient-Inpatient by the facility) that included the patient's personal assets/strengths on which to based active treatment intervention and treatment planning for seven (7) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, and A7). The patient strengths/assets identified were not individualized or descriptive of each patient's attributes, skill and/or interests. This deficient practice resulted in insufficient information to guide the treatment team in developing individualized treatment plans and impaired the treatment team's ability to choose treatment modalities which best utilize the patient's strengths/assets in therapy. (Refer to B117)

IV. Ensure treatment plans for eight (8) of eight (8) active sample patient (A1, A2, A3, A4, A5, A6, A7 and A8) that utilized patients strengths/assets/. The MTPs included a list of patient traits or external support resources labeled as "strengths." There was no documentation of how these assets would be used to support the patient's inpatient treatment. Failure to identify and utilize patient strengths can diminish the effectiveness of treatment. (Refer to B 119)

V. Develop individualized Master Treatment Plans (MTPs) called (Individual Recovery Plan by the facility) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). In addition, many treatment plans contained similarly worded short-term goals, which were not measurable outcome behaviors. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the treatment plans in response to patients need. (Refer to B121)

VI. Develop Master Treatment Plans (MTP's) that evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Interventions were stated as generic monitoring and/or discipline functions. Specific groups assigned to each patient were not included. The method of delivery for these activities were absent. Interventions on the treatment plans did not identify the specific goal being addressed. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each. This failure also potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

VII. Ensure that the name of the staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6 A7 and A8). This practice resulted in the facility's inability to monitor staff's accountability for specific treatment modalities. (Refer to B123)

VIII. Ensure that resources were available to provide for a Therapeutic activities program appropriate to the needs and interest of the patients This failure may results in the treatment that lack the potential toward restoring and maintaining optimal levels of physical and psychological functioning. (Refer to B157 and B158)

Based on record review and interview the facility failed to ensure that the Psychosocial Assessments (called Bio-Psychosocial Assessment by the facility) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) include anticipated Social Work roles in treatment. As a result, critical patient psychosocial information necessary for informed treatment planning decisions were not available to the treatment team.

Findings include:

A. Record Review

1. Patient A1 was admitted for "substance use detox and psychosis." on 3/6/18. The Bio-Psycho-Social Assessment completed on 3/7/18 did not identify specific roles for social work in this patient's treatment.

2. Patient A2 was admitted for "depression, anxiety, and suicidal (risk to self.)" on 3/9/18. The Bio-Psycho- Social Assessment completed on 3/10/18 did not identify specific roles for social work in this patient's treatment.

3. Patient A3 was admitted for "depression, anxiety, substance use detox, psychosis and suicidal (risk to self)." on 3/7/18. The Bio-Psycho-Social Assessment completed on 3/8/18 did not identify specific roles for social work in this patient's treatment.

4. Patient A4 was admitted for "psychosis" on 3/6/18. The Bio-Psycho- Social Assessment completed on 3/7/18 did not identify specific roles for social work in this patient's treatment.

5. Patient A5 was admitted for "depression, psychosis, suicidal (risk to self) and homicidal/violence (risk to others)" on 3/10/18. The Bio-Psycho-Social Assessment completed on 3/11/18 did not identify specific roles for social work in this patient's treatment.

6. Patient A6 was admitted for "depression, anxiety, and suicidal (risk to self.)" on 3/6/18. The Bio-Psycho-Social Assessment completed on 3/7/18 did not identify specific roles for social work in this patient's treatment.

7. Patient A7 was admitted for "anxiety" on 3/2/18. The Bio-Psycho-Social Assessment completed on 3/3/18 did not identify specific roles for social work in this patient's treatment.
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8. Patient A8 was admitted for "substance use detox." on 3/10/18. The Bio-Psycho-Social Assessment completed on 3/11/18 did not identify specific roles for social work in this patient's treatment.

B. Interview.

In an interview with the Social Work Director on 3/13/18 at 4:00 p.m., the missing social work role on the Bio-Psycho-Social Assessment were discussed. She did not dispute the findings.

Based on record review and interview, the facility failed to ensure that the Medical History and Physical Examinations for eight of (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included a neurological examination of cranial nerves II through XII was documented. This failure to record detailed neurological findings could result in the overlooking of treatable neurological conditions and/or inability to document changes from baseline status during the patients' hospitalization. This failure makes it impossible to ascertain progression/worsening of patient's condition on subsequent re-examination.

Finding include:

A. Record Review

1. Patient A1 had a physical examination completed 3/6/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

2. Patient A2 had a physical examination completed 3/10/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

3. Patient A3 had a physical examination completed 3/8/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

4. Patient A4 had a physical examination completed 3/7/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

5. Patient A5 had a physical examination completed 3/10/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

6. Patient A6 had a physical examination completed 3/7/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

7. Patient A7 had a physical examination completed 3/3/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

8. Patient A8 had a physical examination completed 3/11/18. Neurological examination (which was part of the physical examination) "Cranial nerves II to XII, intact."

B. Interview

In a telephone interview on (speaker phone) with the Medical Director and the staff psychiatrist present in the room on 3/13/18 at 1:00 p.m., the neurological examinations were discussed. The Medical Director agreed with the findings and stated, "We learned not to do that a long time ago."

Based on record review and staff interview, the facility failed to provide psychiatric evaluation called (Evaluation & Management Progress Note; New Patient-Inpatient by the facility) that included the patient's personal assets/strengths on which to based active treatment intervention and treatment planning for seven (7) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, and A7). The patient strengths/assets identified were not individualized or descriptive of each patient's attributes, skill and/or interests. This deficient practice resulted in insufficient information to guide the treatment team in developing individualized treatment plans and impaired the treatment team's ability to choose treatment modalities which best utilize the patient's strengths/assets in therapy.

Findings include:

A. Record Review

The following Psychiatric Evaluations (dates of examination in parentheses) were reviewed for patient strengths/assets. A1 (3/6/18), A2 (3/9/18), A3 (3/8/18), A4 (3/7/18, A5 (3/11/18), A6 (3/7/18) and A7 (3/3/18). This review revealed the following findings:

1. Patient A1's Psychiatric Evaluation under the section titled "Strengths" documented the following as strength/asset: "Unclear as pt (patient) unable to report." There was no documented evidence that another attempt had been made to obtain information regarding this patient's assets/strengths.

2. Patient A2's, Psychiatric Evaluation under the section titled "Strengths" documented the following as strength/asset: "friends and family." This statement did not provide specific information regarding the usefulness of this strength/asset in psychiatric treatment and treatment planning.

3. Patient A3's Psychiatric Evaluation, under the section titled "Strengths" documented the following as strength/asset: "Therapy support, dogs." This statement did not provide specific information regarding the usefulness of this strength/asset in psychiatric treatment and treatment planning.

4. Patient A4's Psychiatric Evaluation, under the section titled "Strengths" documented the following as strength/asset: "Therapy support, dogs." This statement did not provide specific information regarding the usefulness of this strength/asset in psychiatric treatment and treatment planning.

5. Patient A5's Psychiatric Evaluation, under the section titled "Strengths" documented the following as strength/asset: "None identified as pt ended the assessment." There was no documented evidence that another attempt had been made to obtain information regarding this patient's assets/strengths.

6. Patient A6's Psychiatric Evaluation, under the section titled "Strengths" documented the following as strength/asset: "My daughter and maybe her dad." Although individualized, the statement did not provide specific information regarding how these family members would be helpful in the treatment and/or aftercare for the patient.

7. Patient A7's Psychiatric Evaluation, under the section titled "Strengths" documented the following as strength/asset: "I have hope" did not provide specific information regarding the usefulness of this asset in psychiatric treatment and treatment planning.

B. Interview

In a telephone interview with the Medical Director in the presence of the unit staff psychiatrist on 3/13/18 at 1:00 p.m., the none specific strengths/assets on the psychiatric evaluation was discussed. The Medical Director agreed with the findings and stated "I understand, we need to coordinate our efforts with our staff in building the electronic record and do a lot of training. This would not happen today."

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7and A8) that utilized patient strengths/assets. The MTPs included a short list of patient traits or external support resources labeled as "strengths." There was no documentation of how these assets would be used to support the patient's inpatient treatment. Failure to identify and utilize patient strengths can diminish the effectiveness of treatment.

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


Findings include:

A. Record Review

1. Patient A1 was admitted on 3/6/18. The MTP dated 3/7/18, in the section titled "Strengths", noted the following: "None identified as patient ended the assessment." No attempt to gather this information was noted. This lack of information hinders

2. Patient A2 was admitted on 3/9/18. The MTP dated 3/10/18, in the section titled "Strengths" noted the following: "Friends and family." There was no evidence on the MTP how the identified strengths were to be used to support the patient's treatment goal(s).

3. Patient A3 was admitted on 3/7/18. The MTP dated 3/9/18 in the section titled "Strengths" noted the following. "No strengths identified." This lack of information hinders the treatment team ability to develop a plan built on patient strengths.

4. Patient A4 admitted on 3/6/18. The MTP dated 3/7/18, in the section titled "Strengths" noted the following: "[Patient] has entitlements. S/he has been living on [her/his] own. S/he has a car and drives. Cooking is also a strength." There was no evidence on the MTP how the identified strengths were to be used to support the patient's treatment goal(s)

5. Patient A5 admitted 3/10/18. The MTP dated 3/11/18, in the section titled "Strengths" noted the following: "Good listener, good at building crafts, got a good marriage and good with kids." There was no evidence on the MTP how the identified strengths were to be used to support the patient's treatment goal(s)

6. Patient A6 admitted on 3/6/18. The MTP dated 3/8/18, in the section titled "Strengths" noted the following: "I'm really nice, friendly, I can draw. Some support." There was no evidence on the MTP how the identified strengths were to be used to support the patient's treatment goal(s).

7. Patient A7 admitted 3/2/18. The MTP dated 3/3/18, in the section titled "Strengths" noted the following: "I am nice to everybody." There was no evidence on the MTP how the identified strengths were to be used to support the patient's treatment goal(s).

B. Staff Interview

1. In a telephone interview with the Medical Director in the presence of the unit staff psychiatrist on 3/13/18 at 1:00 p.m., the none specific strengths/assets on the psychiatric evaluation was discussed. The Medical Director agreed with the findings and stated "I understand, we need to coordinate our efforts with our staff in building the electronic record and do a lot of training. This would not happen today."

2. In an interview with the Nursing Director on 3/13/18 at 2:00 p.m., the identified strengths on the Master Treatment Plans were discussed. She agreed with the findings.

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). In addition, many Master Treatment Plans contained similarly worded short-term goals for patients, which were not measurable outcome behaviors. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patient and may contribute to failure of the team to modify the Master Treatment Plans in response to patient's need.

Findings include:

A. Record Review

1. Patient A1: MTP dated 3/7/18 identified the "Presenting Problem" as "Substance use Detox (detoxification) and Psychosis."

a. Short-term goal: "Safe substance detox" "Reduce/eliminate psychosis." These were not observable, measurable patient behaviors.

b. Short-term goal: "To get released." Goal was not specific, observable and measurable.

2. Patient A2: MTP dated 3/10/18 identified the "Presenting Problem" as "Depression, anxiety, and suicidal (risk to self)."

a. Short-term goal: "Client will experience a reduction in the symptoms of depression." Goal was a staff expectation and non-measurable.

b. Short-term goal: "Client will experience a decrease in symptoms of anxiety." Goal was a staff expectation and non-measurable.

c. Short-term goal: "Reduce/Eliminate suicidal thoughts." Goal was a staff expectation and non- measurable.

3. Patient A3: MTP dated 3/9/18 identified the "Presenting Problem" as "Depression, anxiety, substance use detox, psychosis and suicidal (risk to self)."

a. "Client will experience a reduction in the symptoms of depression." Goal was a staff expectation and non-measurable.

b. Short-term goal: "Client will experience a decrease in symptoms of anxiety." Goal was a staff expectation and non-measurable.

c. Short-term goal: "Safe substance detox." Goal was a staff expectation and non-measurable.

d. Short-term goal: "Reduce/eliminate psychosis." Goal was a staff expectation and non-measurable.

e. Short-term goal: "Reduce/Eliminate suicidal thoughts." Goal was a staff expectation and non- measurable.

4. Patient A4: MTP dated 3/7/18 identified the "Presenting Problem" as "Psychosis."

a. Short-term goal: "Reduce/eliminate psychosis." Goal was a staff expectation and non-measurable.

5. Patient A5: MTP dated 3/11/18 identified the "Presenting Problem" as "Depression, psychosis, suicidal (risk to self), homicidal/violence (risk to others)."

a. Short-term goal: "Client will experience a reduction in the symptoms of depression." Goal was a staff expectation and non-measurable.

b. Short-term goal: "Reduce/eliminate psychosis." Goal was a staff expectation and non- measurable.

c. Short-term goal: "Reduce/Eliminate suicidal thoughts." Goal was a staff expectation and non- measurable.

d. Short-term goal: "Reduce/Eliminate risk to others/violence potential." Goal was a staff expectation and non-measurable.

6. Patient A6: MTP dated 3/8/18 identified the " Presenting Problem" as "Depression, anxiety, suicidal (risk to self)."

a. Short-term goal: "Client will experience a reduction in the symptoms of depression." Goal was a staff expectation and non-measurable.

b. Short-term goal: "Client will experience a decrease in symptoms of anxiety." Goal was a staff expectation and non-measurable.

c. Short-term goal: "Reduce/Eliminate suicidal thoughts." Goal was a staff expectation and non-measurable.

7. Patient A7: MTP dated 3/3/18 identified the "Presenting Problem" as "Anxiety."

a. Short-term goal: "Client will experience a decrease in symptoms of anxiety." Goal was a staff expectation and non-measurable.

8. Patient A8: MTP dated 3/11/18 identified the "Presenting Problem" as "Substance use detox."

a. Short-term goal: "Safe substance detox." Goal was a staff expectation and non-measurable.

B. Interview

In an interview with the Nursing Director on 3/13/18 at 2:00 p.m., the Master Treatment Plans goals were discussed. She agreed with the findings and stated, "that's what we were being taught to write, in the client's words."

Based on observation, record review and interview, the facility failed to develop Master Treatment Plans (MTP's) that evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Interventions were stated in generic monitoring and/or discipline functions, specific groups assigned to each patient were not included, method of delivery for these activities were absent. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each.
Findings include:

A. Record Review

1. Patient A1: MTP dated 3/7/18 identified the "Presenting Problem" as "Substance use Detox (detoxification) and Psychosis."

a. Substance Use Detox: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Addiction screening 1x - Case Manager, Monitor Food/fluid intake 3x/daily, MHT (Mental Health Technician), RN (Registered Nurse), Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All staff, Provide opportunities for client to share feeling daily - RN, Orient client to Person, Place and Time - PRN - All staff, Set clear/consistent limits for negative behaviors - all staff."

b. Psychosis: Generic interventions were: "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Orient client to Person, Place and Time - PRN - All staff, Set clear/consistent limits for negative behaviors - All staff, Monitor sleep patterns daily - MHT, RN, Redirect client to reality-based conversation/behavior PRN, Collateral with Case Manager/Therapist PRN."

2. Patient A2: MTP dated 3/10/18 identified the "Presenting Problem" as "Depression, anxiety, and suicidal (risk to self)."

a. Depression: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Collateral with family/Guardian/significant others PRN- CM (Case Manager). Maintain therapeutic environment to reduce risk- RN, Monitor Food/Fluid intake 3x daily - MHT, RN."

b. Anxiety: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Provide Group education and activities at least 3x daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Provide opportunities for client to share feeling daily - RN, Maintain therapeutic environment to reduce risk - RN, Collateral with family/Guardian/significant others PRN."

c. Suicidal (risk to self): Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Develop personal safety plan - Case Manager, Special observation/precaution for suicide."

3. Patient A3: MTP dated 3/9/18 identified the "Presenting Problem" as "Depression, anxiety, substance use detox, psychosis and suicidal (risk to self)."

a. Depression: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Collateral with Case Manager - Therapist PRN - Collateral with family/Guardian/significant others PRN- CM (Case Manager), Case Manager to assist with discharge planning and linkage, Provide opportunities for client to share feeling daily - RN."

b. Anxiety: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Provide Group education and activities at least 3x daily, Provide Psychoeducation and Support PRN (when necessary) - All staff, Provide opportunities for client to share feeling daily - RN, Collateral with family/Guardian/significant others PRN, Collateral with Case Manager/Therapist PRN, Case Manager to assist with discharge planning and linkage."

c. Substance use detox: Generic interventions were," Addiction screening 1x - Case Manager, Recovery specialist provide SA (substance abuse) program materials and linkage, monitor detox and medicate as ordered - RN."

d. Psychosis: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Monitor sleep patterns daily - MHT, RN, Redirect client to reality-based conversation/behavior PRN, Collateral with Case Manager/Therapist PRN, Collateral with family/Guardian/significant others PRN- CM (Case Manager), Provide activities/groups with minimal stimulation daily - CM, MD (medical doctor) medication management for altered thoughts - daily, Maintain therapeutic environment to reduce risk - RN, Medication management for behavior risk issues daily - MD, Case Manager to assist with discharge planning and linkage."

e. Suicidal (risk to self): Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide Psychoeducation and Support PRN (when necessary) - All staff, Develop personal safety plan - Case Manager, Special observation/precaution for elopement, Case Manage to assist with discharge planning and linkage, Provide activities/groups with minimal stimulation daily- CM, Monitor food/fluid intake 3x daily - MHT, RN, Collateral with Case Manager/Therapist PRN, Collateral with family/Guardian/significant others PRN- CM, Reconcile medications with PCP (patient care plan) w/in (within) 24 hrs. (hours) of admission RN, Provide one-on-one support PRN - All Staff, MD medication management for altered thoughts - daily, Redirect client-based conversation/behavior PRN, Assist with ADLs (activity of daily living) - MHT, RN."

4. Patient A4: MTP dated 3/7/18 identified the "Presenting Problem" as "Psychosis."

a. Psychosis: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group Attendance - 3x Daily, Monitor sleep patterns daily - MHT, RN, Redirect client to reality-based conversation/behavior PRN, Collateral with Case Manager/Therapist PRN, Collateral with family/Guardian/significant others PRN- CM (Case Manager), Provide activities/groups with minimal stimulation daily - CM, MD (medical doctor) medication management for altered thoughts - daily, Maintain therapeutic environment to reduce risk - RN, Medication management for behavior risk issues daily - MD, Case Manager to assist with discharge planning and linkage."

5. Patient A5: MTP dated 3/11/18 identified the "Presenting Problem" as "Depression, psychosis, suicidal (risk to self), homicidal/violence (risk to others)."

a. Depression: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Provide opportunities for client to share feeling daily - RN, Monitor food/fluid intake 3x daily - MHT, RN, Maintain therapeutic environment to reduce risk - RN, Help client find appropriate outlets for anger - All Staff ."

b. Psychosis: Generic interventions were, " Medication monitoring 3x/day (three times daily), Group Attendance - 3x Daily, Redirect client to reality-based conversation/behavior PRN, Maintain therapeutic environment to reduce risk - RN, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All Staff, Provide opportunity to share feeling daily - RN, Set clear/consistent limit for negative behaviors - All Staff, Orient client to person, place and time - All Staff."

c. Suicidal (risk to self): Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide Psychoeducation and Support PRN (when necessary) - All staff, Develop personal safety plan - Case Manager, Provide one-on-one support PRN - All Staff, Help client find appropriate outlets for anger - All Staff, Provide opportunity to share feeling daily - RN, Set clear/consistent limit for negative behaviors - All Staff."

d. Homicidal/violence (risk to others): Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group Attendance - 3x Daily, Redirect client to reality-based conversation/behavior PRN, Collateral with Case Manager/Therapist PRN, Collateral with family/Guardian/significant others PRN- CM (Case Manager), Provide one-on-one support as needed - All Staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Special observation/precaution for elopement, Maintain therapeutic environment to reduce risk - RN, Help client find appropriate outlets for anger - All Staff, Provide opportunities for client to share feeling daily - RN."

6. Patient A6: MTP dated 3/8/18 identified the " Presenting Problem" as "Depression, anxiety, suicidal (risk to self)."

a. Depression: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Provide opportunities for client to share feeling daily - RN, Monitor food/fluid intake 3x daily - MHT, RN, Maintain therapeutic environment to reduce risk - RN, Collateral with family/Guardian/significant others PRN- CM (Case Manager)."

b. Anxiety: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Provide Group education and activities at least 3x daily, Provide one-on-one support as needed - All staff, Provide opportunities for client to share feeling daily - RN, Maintain therapeutic environment to reduce risk - RN, Reconcile medications with PCP (patient care plan) w/in (within) 24 hrs (hours) of admission RN."

c. Suicidal (risk to self): Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide Psychoeducation and Support PRN (when necessary) - All staff, Develop personal safety plan - Case Manager, Provide one-on-one support PRN - All Staff, Maintain therapeutic environment to reduce risk - RN, Collateral with family/Guardian/significant others PRN- CM (Case Manager)."
7. Patient A7: MTP dated 3/3/18 identified the "Presenting Problem" as "Anxiety."

a. Anxiety: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Provide Group education and activities at least 3x daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Provide opportunities for client to share feelings daily - RN, Maintain therapeutic environment to reduce risk - RN, Collateral with Case Manager/Therapist PRN, Case Manager to assist with discharge planning and linkage, Develop personal safety plan, Monitor Food/Fluid intake 3x daily - MHT, RN, Monitor sleep pattern - MHT, RN, Orient client to person, Place and time - PRN - All Staff, Assist with daily ADLs - MHT, RN, Reconcile medications with PCP w/in 24 hrs. of admission RN."

8. Patient A8: MTP dated 3/11/18 identified the "Presenting Problem" as "Substance use detox."

a. Substance use detox: Generic interventions were, "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Addiction screening 1x - Case Manager, Monitor Food/fluid intake 3x/daily, MHT (Mental Health Technician), RN (Registered Nurse), Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All staff, Provide opportunities for client to share feeling daily - RN, Orient client to Person, Place and Time - PRN - All staff, Set clear/consistent limits for negative behaviors - All Staff, Recovery Specialist provide SA materials and linkage, Maintain therapeutic environment to reduce risk - RN, Monitor sleep patterns daily - MHT, RN, MD medication management for altered thoughts - daily, Redirect client to reality based conversation/behavior PRN."

B. Interview

1. In an interview with RN1 on 3/13/18 at 10:50 a.m., the Master Treatment Plans generic interventions were reviewed. The RN1 concurred with the findings.

2. In an interview with RN2 on 3/13/18 at 12:30 p.m., the Master Treatment Plans generic interventions were reviewed. The RN2 concurred with the findings.

3. In an interview with the Medical Director on 3/13/18 at 1:00 p.m., the Master Treatment Plans generic interventions were reviewed. She agreed with the findings and stated, "ok, I understand, will coordinate and build electronic records to address those needs, and will need to do training"

4. In an interview with the Nursing Director on 3/13/18 at 2:00 p.m., the Master Treatment Plans nursing interventions were reviewed. She agreed with the findings and stated, "ok, they are very generic."

Based on record review and interview, the facility failed to ensure that the primary responsible staff were identified by name for treatment interventions listed on the Master Treatment Plan for 8 (eight) of 8 (eight) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8.) Instead, each intervention had the discipline title such as ("RN, MTH, CM, MD and All Staff"), and on some neither disciple nor staff name was listed as having primary responsibility for the treatment intervention. This failure can result in lack of staff accountability for the intervention, and failure to deliver treatment to meet patients' identified needs.

Findings include:

A. Record Review

1. Patient A1: MTP dated 3/7/18 identified the "Presenting Problem" as "Substance use Detox (detoxification) and Psychosis." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Addiction screening 1x - Case Manager, Monitor Food/fluid intake 3x/daily, MHT (Mental Health Technician), RN (Registered Nurse), Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All staff, Provide opportunities for client to share feeling daily - RN, Orient client to Person, Place and Time - PRN - All staff, Set clear/consistent limits for negative behaviors - all staff."

2. Patient A2: MTP dated 3/10/18 identified the "Presenting Problem" as "Depression, anxiety, and suicidal (risk to self)." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Collateral with family/Guardian/significant others PRN- CM (Case Manager). Maintain therapeutic environment to reduce risk- RN, Monitor Food/Fluid intake 3x daily - MHT, RN."

3. Patient A3: MTP dated 3/9/18 identified the "Presenting Problem" as "Depression, anxiety, substance use detox, psychosis and suicidal (risk to self)." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Collateral with Case Manager - Therapist PRN - Collateral with family/Guardian/significant others PRN- CM (Case Manager), Case Manager to assist with discharge planning and linkage, Provide opportunities for client to share feeling daily - RN."

4. Patient A4: MTP dated 3/7/18 identified the "Presenting Problem" as "Psychosis." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group Attendance - 3x Daily, Monitor sleep patterns daily - MHT, RN, Redirect client to reality-based conversation/behavior PRN, Collateral with Case Manager/Therapist PRN, Collateral with family/Guardian/significant others PRN- CM (Case Manager), Provide activities/groups with minimal stimulation daily - CM, MD (medical doctor) medication management for altered thoughts - daily, Maintain therapeutic environment to reduce risk - RN, Medication management for behavior risk issues daily - MD, Case Manager to assist with discharge planning and linkage."

5. Patient A5: MTP dated 3/11/18 identified the "Presenting Problem" as "Depression, psychosis, suicidal (risk to self), homicidal/violence (risk to others)." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Monitor sleep patterns daily - MHT, RN, Provide opportunities for client to share feeling daily - RN, Monitor food/fluid intake 3x daily - MHT, RN, Maintain therapeutic environment to reduce risk - RN, Help client find appropriate outlets for anger - All Staff ."

6. Patient A6: MTP dated 3/8/18 identified the " Presenting Problem" as "Depression, anxiety, suicidal (risk to self)." The following interventions identified the discipline but not the responsible staff. " Medication monitoring 3x/day (three times daily), Group Attendance - 3x Daily, Redirect client to reality-based conversation/behavior PRN, Maintain therapeutic environment to reduce risk - RN, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All Staff, Provide opportunity to share feeling daily - RN, Set clear/consistent limit for negative behaviors - All Staff, Orient client to person, place and time - All Staff."

7. Patient A7: MTP dated 3/3/18 identified the "Presenting Problem" as "Anxiety." The following interventions identified the discipline but not the responsible staff. "Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Provide Group education and activities at least 3x daily, Provide one-on-one support as needed - all staff, Provide Psychoeducation and Support PRN (when necessary) - All staff, Provide opportunities for client to share feelings daily - RN, Maintain therapeutic environment to reduce risk - RN, Collateral with Case Manager/Therapist PRN, Case Manager to assist with discharge planning and linkage, Develop personal safety plan, Monitor Food/Fluid intake 3x daily - MHT, RN, Monitor sleep pattern - MHT, RN, Orient client to person, Place and time - PRN - All Staff, Assist with daily ADLs - MHT, RN, Reconcile medications with PCP w/in 24 hrs. of admission RN."

8. Patient A8: MTP dated 3/11/18 identified the "Presenting Problem" as "Substance use
detox." The following interventions identified the discipline but not the responsible staff.
"Medication Management Daily - MD, Medication monitoring 3x/day (three times daily), Group attendance - 3x/daily, Provide one-on-one support as needed - all staff, Addiction screening 1x - Case Manager, Monitor Food/fluid intake 3x/daily, MHT (Mental Health Technician), RN (Registered Nurse), Provide Psychoeducation and Support PRN (when necessary) - All staff, Help client find appropriate outlets for anger - All staff, Provide opportunities for client to share feeling daily - RN, Orient client to Person, Place and Time - PRN - All staff, Set clear/consistent limits for negative behaviors - All Staff, Recovery Specialist provide SA materials and linkage, Maintain therapeutic environment to reduce risk - RN, Monitor sleep patterns daily - MHT, RN, MD medication management for altered thoughts - daily, Redirect client to reality based conversation/behavior PRN."

B. Interview

1. In an interview with RN1 on 3/13/18 at 10:50 a.m., the RN1 was unable to identify which particular nurse was responsible for the interventions on the patient's Master Treatment Plans.
2. In an interview with RN2 on 3/13/18 at 12:30 p.m., the Master Treatment Plans interventions were reviewed. The RN2 concurred with the findings that the nurse responsible was not identified on the treatment plans.

3. In an interview with the Nursing Director on 3/13/18 at 2:00 p.m., the Master Treatment Plans nursing interventions were reviewed. She agreed, that only the various disciplines were identified on the treatment plans.

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

I. Provide Therapeutic/Rehabilitative services based on the assessed needs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Instead the patients are required to attend all groups on the unit program schedule regardless of their treatment needs. The facility has a contract with a recreational therapy group that is limited to oversite of scheduled group activities and provide groups outlines to be followed by MHT's and Case Managers when conducting group activities. Failure to have trained therapeutic service staff assessing the needs of the patient, participating in planning and implementing the delivery of care result in patients not reaching optimal level of physical and psychological functioning. (Refer to B157)

II. Employ Therapeutic/Rehabilitative services staff to assess the needs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The facility has a contract with a recreational therapy group that is limited to oversite of scheduled group activities and to provide group outlines to be followed by MHT and Case Managers when conducting group activities. Failure to have trained therapeutic service staff assessing the needs of the patient, participating in planning and implementing the delivery of care result in patients not reaching their optimal level of physical and psychological functioning. (Refer to B158)

III. Provide documented evidence showing Mental Health Technicians (MHTs) were competent to provide therapeutic activity groups listed on the unit program scheduled. Specifically, MHTs provided most of the therapeutic activities titled "Therapeutic Activity, Journaling, Goal Review, Relaxation Group." This failure results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning. (Refer to B158)

IV. In addition, the Director of Social failed to monitor and take corrective action to ensure the anticipated role of social work in treatment was included in the Bio-Psycho-Social Assessment for 8 of 8 (A1, A2, A3, A4, A5, A6, A7, and A8) active sample patients. This failure results in a lack of professional social work information in treatment planning. (Refer to B152)

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

I. Master Treatment Plans (MTPs) that were based on patient strengths (as well as disabilities) for five (5) of eight (8) active sample patients (A2, A4, A5, A6, and A7.) The MTPs listed external resources, e.g., "friends and family, I'm really nice, got a good marriage" as patient strengths/assets and/or failed to specify how identified patient strengths/assets would be used to support the inpatient treatment. Two (2) of eight (8) active sample patients (A1 and A3) had no strengths identified. Failures to identify and incorporate patient strengths in the Master Treatment Plan diminish the effectiveness of treatment interventions and can hamper the patient's achievement of treatment goals. (Refer to B119).

II. Ensure that the individualized Master Treatment Plans (MTPs) identified patient-related short-term goals stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). In addition, many of the Master Treatment Plans contained similarly worded short-term goals for patients. This deficient practice hinders the treatment team's ability to measure behavioral changes and may contribute to failure of the team to modify the Master Treatment Plans. (Refer to B121).

III. Develop Master Treatment Plans (MTP's) that evidenced individualized treatment interventions with specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Interventions were stated as generic monitoring and/or discipline functions. The name of the groups and the method of delivery was not identified. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions and the purpose for each. (Refer to B122).

IV. Ensure that the name of the responsible physician for interventions identified on the Master Treatment Plans (MTPs) was included. This practice resulted in the facility's inability to monitor staff's accountability for modalities. (Refer to B123).

Interview

In a telephone interview with the Medical Director on 3/13/18 at 1:00 p.m., the none specific strengths/assets on the psychiatric evaluation, psychiatric problem statements, short-term goals, interventions and responsible person on the MTPs were discussed. The Medical Director agreed with the findings and stated "I understand, we need to coordinate our efforts with our staff in building the electronic record and do a lot of training. This would not happen today."

Based on observation, record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. Short-term goals in MTPs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) were written in observable, measurable and behavioral terms to address the individual patient presenting problems and needs (Refer to B121)

II. Active treatment interventions implemented by Registered Nurses for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) were not linked to specific treatment goals. The listed nursing intervention were routine, generic discipline functions expected to be performed by nursing staff for all patients. Failure to develop focused, individualized interventions can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122)

III. Ensure that the name and of the nursing staff person(s) responsible for specific interventions identified on the Master Treatment Plans (MTPs). This practice resulted in the facility's inability to monitor staff's accountability for modalities. (Refer to B123)


A. Staff Interview

1. In an interview with the Nursing Director on 3/13/18 at 2:00 p.m., the Master Treatment Plans nursing goals and interventions were reviewed. She acknowledged that the treatment plans goals were not written in observable and measurable patient behaviors to be achieved and nursing interventions were generic and routine nursing functions.

Based on record review and interview, the Director of Social Work failed to ensure that the anticipated role of social work in treatment was included in the Bio-Psycho-Social Assessment for 8 of 8 (A1, A2, A3, A4, A5, A6, A7, and A8) active sample patients. This failure results in a lack of professional social work information in treatment planning. (Refer to B108).

Findings include:

A. Record review

I. The following Bio-Psycho-Social Assessments (dates in parentheses) failed to ensure

1. Description of the social worker's role in treatment and discharge planning was included in the following Bio-Psych-Social Assessments: Patient A1 (3/7/18), A2 (3/10/18), A3(3/8/18), A4(3/7/18), A5(3/11/18), A6(3/7/18), A7(3/3/18) and A8(3/11/18). (Refer to B108)

II. The name of the responsible social worker/case manager for interventions identified on the Master Treatment Plans (MTPs) was included. This practice resulted in the facility's inability to monitor staff's accountability for modalities. (Refer to B123)

B. Interview
In an interview with the Social Work Director on 3/13/18 at 4.00 p.m. she acknowledged the Bio-Psycho-Social Assessments lacked the role of the social worker and name of the responsible social worker.

Based on record review and interview, the facility failed to provide Therapeutic/Rehabilitative services based on the assessed needs of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The facility has a contract with a recreational therapy group that is limited to oversite of scheduled group activities and to provide group outlines to be followed by MHT and Case Managers when conducting group activities. All staff were given a one-hour in-service on the use of the material provided by the consulting Certified Therapeutic Recreation Specialist (CTRS). Failure to have trained therapeutic service staff assessing the needs of the patient, participating in planning and implementing the delivery of care may result in patients not reaching optimal level of physical and psychological functioning.

Findings include:

A. Document Review

1. The Service Agreement dated 8/8/201 was review. In the section titled services to be performed list the following "Staff training on client screening for Recreational Therapy referral, Staff training on activity-based therapeutic interventions, Review of daily/weekly activity schedule and consultation and Recreational Therapy individual sessions as requested per referral." There is not documentation in the patients record that screening was done. The groups on the unit schedule is listed as therapeutic group with no specifics of what the group entailed.

II. Documentation of staff in-service training on activity-based therapeutic intervention was requested. A sign sheet with no detail as to what was presented was obtained.

B. Interview

In an interview with The Director of Nursing on 3/13/18 at 4.33 p.m. the need for a therapeutic program was discussed. The DON stated, "We do not have a specific program for therapeutic service, but we have an agreement to provide oversite for scheduling of group activities." She also stated the person on contract do not participate in the groups or assessment of patients.

Based on observation and interview, the facility failed to:

I. Employ a qualified Therapeutic Activities staff to provide and document active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6 A7 and A8). Specifically, the facility did not have an activity therapist to complete therapeutic activities assessments to ensure appropriate input into the formulation of the Master Treatment Plan. This failure results in patients not receiving a full complement of therapies, patients not being assessed regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities.

II. Provide documented evidence showing Mental Health Technicians (MHTs) competency to provide therapeutic activity groups. Specifically, MHTs provided most of the therapeutic activities titled "Therapeutic Activity, Journaling, Goal Review, Relaxation Group." MHTs did not have documented evidence except for a signature sheet for one hour of in-service that showed training to facilitate these groups; which they were assigned to lead. This failure results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings Include:



A. Record Review

1. There was no Therapeutic Activities Assessments located in the electronic medical records.

2. The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (3/7/18), A2 (3/10/18), A3 (3/9/18), A4 (3/7/18), A5 (3/11/18), A6 (3/8/18), A7 (3/3/18) and A8 (3/11/18). This review revealed no therapeutic intervention statements.

B. Interview

In an interview on 3/13/18 at 2:00 p.m. with the Nursing Director, of not having an Activity Therapist, she stated that they have an Activity Therapist on a consultant basis from an agency who developed tools for the MHT and the Case Managers to use as a guide when conducting groups. She further stated that, there is no therapeutic activities program for the hospital and all staff including MHT received one (1) hour of training.

III. Mental Health Technicians assigned to provide Therapeutic Activities

A. Document Review

1. The "Patient Daily Activity Schedule," listed the following groups reported by the facility: "Therapeutic Activities Groups, Community Meeting, journaling, Goal Review/Relaxation Group, Recreational Time, Provide psychoeducation and support." All patients were expected to attend all groups irrespective of their problem and their individual needs.

2. The Master Treatment Plans for the active sample patients contained the following identical or similarly worded intervention assigned to Mental Health Technicians (MHTs): "MHT provide psychoeducation and support - All Staff, Set clear/consistent limits for negative behaviors - All Staff, Orient client to Parson, Place and Time - All Staff, provide one-on-one support - All Staff." The facility did not provide documentation regarding education/training and competency evaluations for MHTs to facilitate the therapeutic activities groups except for a signature sheet.

3. During observation on 3/12/18 from 2:00 to 3:00 p.m., MHT 1 conducted a group titled, "Recreational time." A review of the training binder revealed that the facility did not have documented evidence to substantiate education/training for the MHT except a signature sheet verifying MHT attended.

C. Interviews

1. In a discussion on 3/12/18 at 2:10 p.m., the RN1 stated we do not have a Staff Trainer.

2. In an interview on 3/14/18 at 11:30 a.m. with Case Manager 1, Therapeutic/Rehabilitation program was discussed. Case Manager 1 stated, "there are no recreational therapists on staff, it would be wonderful if they could have an Occupational Therapist or Recreational Therapist on staff, it would improve the service here." She also reported that Mental Health Technicians were assigned to do "groups."