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Based on record review and staff interview, the facility failed to complete an initial Psychiatric Evaluation within 60 hours of admission for 3 of 6 sample patients (A2, B2 and B4).. Failure to complete an initial Psychiatric Evaluation in a timely fashion hampers the team's ability to develop a comprehensive treatment plan.

Findings include:

A. Record Review

1. Patient A2 was admitted to the hospital on 6/3/2011. The initial Psychiatric Evaluation (termed "Psychiatric Assessment Inquiry" in this hospital) for this patient was completed on 6/9/2011, 6 days after the admission.

2. Patient B2 was admitted to the hospital on 6/1/2011. The Initial Psychiatric Evaluation for this patient was completed on 6/9/2011, 8 days after the admission.

3. Patient B4 was admitted to the hospital on 6/2/2011. The Initial Psychiatric Evaluation for this patient was completed on 6/9/2011, 7 days after the admission

B. Staff Interview

In an interview on 6/21/2011 at 9:15AM, the Medical Director agreed with the surveyor's findings.

Based on document review and interview, the facility failed to develop complete Treatment Plans (MTPs) with input from all disciplines within 10 days of admission (as required by policy) for 3 of 6 active sample patients (A2, B1 and B4). Failure to develop a Master Treatment Plan (MTP) in a timely manner hampers the staff's ability to provide coordinated treatment early in the hospital stay and potentially delays effective treatment and discharge.

Findings include:

A. Record Review

1. Patient A2 was admitted on 6/3/11; the MTP was dated 6/15/11, 12 days after admission.

2. Patient B1 was admitted on 3/16/11; the MTP was dated 3/30/11, 14 days after admission.

3. Patient B4 was admitted on 6/2/11; the MTP was dated 6/15/11, 13 days after admission.

B. Policy Review

1. The State of Minnesota "Policy Number: 6045" "Effective Date: January 18, 2010" titled "Client Care" "Assessment and Treatment Planning" reads as follows on page 2:
"Treatment Plan"... "The written record of treatment planning. This document directs all treatment activities conducted by the treatment team. Every client interaction should be for therapeutic effect as defined in the treatment plan."

2. A document entitled "Treatment Plans and Planning" was provided by the Director of Nursing on the first day of the survey. The footnote on the document read: "Minnesota Department of Human Services" "Child and Adolescent Behavioral Health Services Procedures Manual." There was no signature, date, or identifying number on the document. The second paragraph under "Definitions:" included the following statements: "Master Treatment Plan (MTP): The Master Treatment Plan is assessment based and the focus of the team's activity in relation to the key areas of identified patient needs that resulted in the person's admission to CABHS [Child and Adolescent Behavioral Health Services]. The MTP shall be completed by the end of the 10-day [sic] following admission."

C. Interview

1. In an interview on 6/21/11 at 9:15a.m., the Medical Director agreed that some patients do not have a complete Master Treatment Plan on the chart within 10 days and that a written plan found within the time frame on some charts did not meet the requirement for a MTP.

2. In an interview on 6/21/11 at 1:30p.m., the Director of Nursing (DON) stated that the "Policy and Procedures" document provided is "the procedure we follow." The number, date, and approving signatures were not on the document. The DON agreed that the complete MTP was not always on the chart within 10 days.

Based on record review, staff interview and policy review, the Medical Director failed to:

I. Assure that an initial Psychiatric Evaluation was completed within 60 hours of admission to the hospital for 3 of 6 sample patients (A2, B2 and B4). Failure to complete a Psychiatric Evaluation in a timely fashion hampers the team's ability to develop a comprehensive treatment plan. (Refer to B111)

II. Assure that a complete Master Treatment Plan (MTP) was developed within 10 days of admission for 3 of 6 active sample patients (A2, B1 and B4). Failure to develop a Master Treatment Plan (MTP) with input from all disciplines in a timely manner hampers the staff's ability to provide coordinated treatment early in the hospital stay and potentially delays effective treatment and discharge. (Refer to B118)