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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.

Based on record review and interview, the facility failed to provide Master Treatment Plans of 8 of 8 active sample patients (A1, A2, A3, A4, B5, B6, C7 and C8) that defined short-term and long-term goals as specific, measurable patient behaviors to be achieved. This deficient practice compromises staff's ability to evaluate patient progress in treatment and make necessary modifications in patients' treatment plans.

Findings include:

A. Record Review

1. Patient A1's presenting problem #1 was "Anxiety." The long-term goal on the treatment plan dated 5/7/11 was "Decrease anxiety so pt. (patient) can care for self and be treated at a less intensive level of care." The short-term objective was "Pt. (patient) to verbalize when experiencing increased anxiety and alternatives coping skills they can use to decrease their anxiety prn." The goal/objective was not measurable patient outcome behaviors.

2. Patient A2's presenting problem #1 was "Psychosis." The long-term goal on the treatment plan dated 5/8/11 was "VS (Vital Sign) and ADL's stabilized. Pt. (Patient) remains on meds." The short-term objective was "Pt. (patient) will attend all gr. (groups) and interact with peers and staff." The short-term goal failed to include a target date for expected achievement. The patient's attendance at groups also was a staff goal for the patient's participation in treatment, not a patient outcome to be achieved.

3. Patient A3's presenting problem #2 was "Alteration in Safety." There was no listed long-term goal on the treatment plan dated 4/22/11. The short-term objective was "least restrictive management will be utilized to manage pt. (patient) bx. (behavior)." The short-term objective was not a measurable patient outcome behavior.

4. Patient A4's presenting problem #1 was "Bx (behavior) dangerous to self/others." The long-term goal on the treatment plan dated 5/3/11 was "decrease freq (frequency)/intensity of bxs (behaviors) to cont (continue) tx (treatment) outpt (outpatient)." The short-term objectives were "Patient will choose to attend groups daily" and "Patient will choose to leave her room and interact with peers daily" The goal/objectives were not measurable patient outcome behaviors.

5. Patient B5's presenting problem #1 was "Alteration in mood/safety." The long-term goal on the treatment plan dated 5/10/11 was "eliminate alteration in mood/safety." The short-term objective was "Pt. (patient) will attend & participate in groups daily." The long-term goal was not measurable. The short-term objective was a staff goal for the patient's participation in treatment, not a measurable patient outcome behavior.

6. Patient B6's presenting problem #1 was "Ineffective individual coping." The long-term goal on the treatment plan dated 5/8/11 was "Increase ability to cope in positive ways - no longer suicidal." The short-term objective was "will attend at least 3 unit groups each day." The long term goal was not measurable as stated. The short-term objective was a staff goal for patient participation in treatment, and there was no target date for expected achievement of the objective.

7. Patient C7's presenting problem #1 was "Cocaine Dependence." The long-term goal on the treatment plan dated 5/6/11 was "long term sobriety." The short-term objectives were "Patient will explore relapse in depth to identify unhealthy patterns that lead to relapse"; "Patient will develop a relapse prevention plan identifying ways to cope with triggers" and "Patient will identify, challenge and replace irrational thoughts about drugs and about his/herself." These objectives were not measurable as stated. There also was no target date for the patient's achievement of the objectives.

8. Patient C8's presenting problem #1 was "ETOH Dep" (Dependency)." The long-term goal on the treatment plan dated 4/23/11 was "Sobriety." The short-term objectives were "Patient will attend all groups"; "Client will identify impact of drinking to self and others" and "Client will develop a plan to address triggers." The objectives were not measurable as stated. There also were no target dates for the patient's achievement of the objectives.

B. Interview

In an interview on 5/13/11 at approximately 9:30AM, the Director of Clinical Social Work Services acknowledged that the goals/objectives on the MTPs were not measurable.





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Based on record review and interview, the facility failed to provide Master Treatment Plans that specified individualized and focused interventions for 8 of 8 active sample patients (A1, A2, A3, A4, B5, B6, C7 and C8). The MTP interventions were checklists of generic tasks for specific disciplines instead of individualized interventions based on assessed patient needs. They also failed to specify the treatment modalities that were to be used. In addition, The MTPs for patients A2, C7, and C8 lacked Recreational Therapy interventions. The MTP for patient A4 had no nursing interventions, and the MTP for C8 had no Psychiatrist interventions. These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record Review (MTP dates in parentheses):

1. Patient A1 (5/7/11). The MTP only included generic tasks for the problem "Anxiety." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" Recreational Therapy "Complete recreational therapy assessment." The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

2. Patient A2 (5/8/11). The MTP only included generic tasks for the problem "Psychosis." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication." There were no Recreational Therapy interventions. In addition, the MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

3. Patient A3 (4/22/11). The MTP only included generic tasks for the problem "Psychosis -Altered thought process." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" Recreational Therapy "Complete recreational therapy assessment." The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

4. Patient A4 (5/3/11). The MTP only included generic tasks for the problem "Behavior dangerous to self/others." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Recreational Therapy: "Complete recreational therapy assessment." There were no nursing interventions. In addition, the MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

5. Patient B5 (5/10/11). The MTP only included generic tasks for the problem "Alteration in mood/safety." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" Recreational Therapy "Complete recreational therapy assessment." The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

6. Patient B6 (5/8/11). The MTP only included generic tasks for the problem "Ineffective individual coping." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" Recreational Therapy "Complete recreational therapy assessment." The MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

7. Patient C7 (5/6/11). The MTP only included generic tasks for the problem "Cocaine Dependency." These were: Psychiatrist "Complete Initial Psychiatric Assessment: Prescribe and evaluate, adjust medication as appropriate." Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" There were no Recreational Therapy interventions. In addition, the MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

8. Patient C8 (4/23/11). The MTP only included generic tasks for the problem "ETOH Dependency." These were: Social Work "Complete bio-psychosocial assessment." Nursing "Complete nursing assessment: Monitor/assess for side effects and response to medication" There were no Psychiatrist or Recreational Therapy interventions. In addition, the MTP did not specify what modalities were to be used or what unit activities the patient was to attend.

B. Interviews

1. In an interview on 5/11/11 at approximately 10:00AM, the Medical Director acknowledged that the interventions on the MTP were not individualized for patients.

2. In an interview on 5/11/11 at approximately 1:45PM, RN 1 acknowledged that the interventions on the treatment plans of patients C7 and C8 were only check lists for each discipline, not individualized interventions to address the stated goals/objectives.





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