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Based on record review, policy review and interview, it was determined that for 2 of 8 sample patients (C7 and C8) and 6 of 6 non-sample patients (E1, E2, E3, E4, E5 and E6), the facility failed to document a psychiatric evaluation. The absence of this patient information hinders the treatment team's ability to formulate an appropriate problem list and plan appropriate treatment.

Findings include:

A. Record review

1. Patient C7 was admitted on 5/6/11. There was no Psychiatric Evaluation in the record.

2. Patient C8 was admitted on 4/21/11. There was no Psychiatric Evaluation in the record.

3. Patient E1 was admitted on 5/3/11. There was no Psychiatric Evaluation in the record.

4. Patient E2 was admitted on 4/19/11. There was no Psychiatric Evaluation in the record.

5. Patient E3 was admitted on 4/28/11. There was no Psychiatric Evaluation in the record.

6. Patient E4 was admitted on 5/2/11. There was no Psychiatric Evaluation in the record.

7. Patient E5 was admitted on 4/16/11. There was no Psychiatric Evaluation in the record.

8. Patient E6 was admitted on 5/5/11. There was no Psychiatric Evaluation in the record.

B. Policy Review

Harbor Oaks Hospital policy titled "Scope of Services- Chemical Dependency Program" applicable to the "Co-Occurring Disorders Unit," dated 10/2009, revised 7/2010) was reviewed. On page 4 under the "Assessment" section, there was no stated requirement for a Psychiatric Evaluation. The only required assessments included: Intake Screening, Nursing Assessment, History and Physical Exam, Diagnostic Testing (if required), Psychosocial Assessment, Leisure Functioning Assessment.

C. Interview

In an interview on 5/12/11 at 10AM, the Medical Director stated that he did not know that a Psychiatric Evaluation was required on the Chemical Dependency unit. He said that these evaluations were only done on a consultation basis if requested by the attending physician. The Medical Director said that he was aware that these are Medicare certified beds in the hospital.

Based on record review, policy review and interview, the facility failed to ensure that 2 of 8 active sample patients (C7 and C8) and 6 of 6 non-sample patients (E1, E2, E3, E4, E5 and E6) received a psychiatric evaluation containing a mental status examination. This deficient practice results in insufficient information to obtain a clear picture of the thought processes, content and cognition of patients on admission. It also results in insufficient data to assist staff in understanding a patient's diagnosis and accurately assess for changes.

Findings include:

A. Record Review

1. Patient C7 was admitted on 5/6/11. There was no psychiatric evaluation containing a mental status examination in the record.

2. Patient C8 was admitted on 4/21/11. There was no psychiatric evaluation containing a mental status examination in the record.

3. Patient E1 was admitted on 5/3/11. There was no psychiatric evaluation containing a mental status examination in the record.

4. Patient E2 was admitted on 4/19/11. There was no psychiatric evaluation containing a mental status examination in the record.

5. Patient E3 was admitted on 4/28/11. There was no psychiatric evaluation containing a mental status examination in the record.

6. Patient E4 was admitted on 5/2/11. There was no psychiatric evaluation containing a mental status examination in the record.

7. Patient E5 was admitted on 4/16/11. There was no psychiatric evaluation containing a mental status examination in the record.

8. Patient E6 was admitted on 5/5/11. There was no psychiatric evaluation containing a mental status examination in the record.

B. Policy review

Harbor Oaks Hospital policy titled "Scope of Services- Chemical Dependency Program," dated 10/2009 and revised 7/2010 (applicable to the "Co-Occurring Disorders Unit") on page 4 under the "Assessment" section included no requirement for a Psychiatric Evaluation. The only required assessments were: Intake Screening, Nursing Assessment, History and Physical Exam, Diagnostic Testing (if required), Psychosocial Assessment, Leisure Functioning Assessment.

C. Interview

In an interview on 5/12/11 at 10AM, the Medical Director stated that he did not know that a Psychiatric Evaluation was required on the Chemical Dependency unit. He said that these evaluations were only done on a consultation basis if requested by the attending physician. The Medical Director stated that he was aware that these are Medicare certified beds in the hospital.