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Based on staff interviews, review of personnel files, tour and observation of the facility, review of pertinent hospital wide policies and procedures, and review of medical records, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with:
42 CFR 482.28 Food and Dietetic Services
42 CFR 482.41 Physical Environment
42 CFR 482.42 Infection Control

Based on a tour of the Acute Psychiatric Services Unit, review of facility policy and procedure, and staff interview, it was determined that the facility failed to provide all patients with the right to maintain their valuables.

Findings include:

Reference: Facility policy titled, "Patient Search and Securing of Valuables" states, "... Procedure: ... 8. All medications that cannot be sent home are given to the nurse, who sends them to the Pharmacy for storage. The medication sent to the Pharmacy is noted on a "Valuables Inventory & Disposition Form." The staff lists the item and description on the form at admission. Upon discharge the medication is returned to patient and patient signs form. ..."

1. During a tour of the Acute Psychiatric Services Unit at the Piscataway Campus on 2/15/16, the following was noted in the medication room:

a. A filled prescription for Sertraline HCL (hydrochloride) 50 mg (milligrams) dated 3/28/14 for Patient #5. Patient #5 is not currently a patient at the facility.

b. A filled prescription for Tamsulosin 0.4 mg dated 11/18/16 for Patient #6. Patient #6 is not currently a patient at the facility.

2. These medications were not sent to the Pharmacy for storage.

3. These medications were not returned to the patients upon discharge.

4. The above policy was not implemented.

5. The above findings were confirmed with Staff #9.

Based on observation, review of facility policies and procedures, and staff interview conducted on 2/15/17, it was determined that the facility failed to ensure the patient receives care in a safe setting.

Findings include:

Reference #1: Facility policy titled, "Patient Search and Securing of Valuables" states,"... Procedure: 10. Nursing staff are responsible for monitoring the use of all potentially harmful materials by patients, and ensuring the safe storage of these items before and after patient use (see policy entitled "Dangerous Items")."

Reference #2: Facility policy titled, "Dangerous Items - Acute Inpatient" states, "... Procedure: 3. ... c. ... iii. Belts ..."

1. During a tour of the Acute Inpatient Unit on 2/15/17, the following was observed:

a. Patients were not assigned to Room #236 and Room #236 was empty.

(i) A belt was found on the top shelf of the closet.

b. According to facility policy, a belt is a dangerous item. (Reference #2)

(i) Facility staff did not ensure the safe storage of a dangerous item.

2. These findings were confirmed with Staff #1.

Based on review of one of two medical records of patients who were physically restrained, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure the implementation of hospital policy when the use of restraints was necessary.

Findings include:

Reference: Facility policy titled "Personal Restraint in Acute Services Child and Adolescent Programs" states, "... Policy ... Personal restraint is used to prevent patients from harming themselves or other people. ... Less restrictive alternatives are considered first. ..."

1. Review of Medical Record #10 revealed the following:

a. A personal restraint was initiated on 9/19/16 at 8:15 PM.

b. There was no documented evidence that less restrictive alternatives were considered first.

2. The facility policy referenced above was not implemented.

3. These findings were confirmed with Staff #22 and Staff #23.

Based on medical record review and interview with administrative staff, it was determined that the facility failed to ensure that nursing personnel provided nursing care for each patient in accordance with the individual needs of each patient.

Findings include:

1. Review of the medical record of Patient #8, revealed:

a. A multidisciplinary care plan dated 1/31/17 stated:

(i) "Intervention: (First name of patient)'s vital signs will be assessed as per MD orders. Provider: Nurse Name (Staff #54) Two time (s) per Day for 4 day/days" Review of nursing documentation indicated that only one set of vital signs was taken on 1/31, 2/1, and 2/2/17. There was no documentation of any vital signs being taken on 2/3/17. There was no documentation of why only one set of vital signs were taken on the first three days and none on the fourth day. Staff #15 agreed with the findings.

(ii) "Intervention: "(First name of patient) will be observed for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. Provider: Nurse Name (Staff #54) Two time (s) per Day for 4 day/days" Review of the medical record did not indicate that any of the assessments were made. Staff #15 agreed with the findings.

(iii) "Intervention: Fluids will be encouraged Provider: Nurse Name (Staff #54) Three time (s) per Day for 4 day/days" There was no documentation that fluids were encouraged at any time during the first four days. Staff #15 agreed with the findings.

b. A DOCTOR'S ORDERS sheet included the order dated 1/31/17 at 12:07 PM:
"Change OBSERVATION LEVEL NOW
Level 1
q (every) 15min checks
to OBSERVATION LEVEL NOW
One to One, criteria per policy
Start: 01/31/17 12:08"
Review of the INTENSE OBSERVATION flowsheet indicated that he/she was maintained on "Q 15 minutes" checks from 8:00 AM until 11:45 PM on 1/31/17. There was no documentation that the nurse who acknowledged the change in the level of observation changed the patient's observation level to one to one and notified the staff monitoring the patient of the change. Staff #15 agreed with the findings.

2. Review of the medical record of Patient #7 indicated that he/she was administered Benadryl 25mg by mouth at 5:15M on 2/8/16 for moderate agitation. There was no documentation that nursing staff assessed the effectiveness of the administered medication. Staff #15 agreed with the findings.

Based on observation and staff interview conducted on 2/15/17, it was determined that medications are dispensed by the pharmacy without a pharmacy label permanently affixed to the medication container in accordance with acceptable standards of practice.

Findings include:

1. During an observation at 10:45 AM, one open vial of Lantus insulin and one open vial of Novolin R insulin were found in the medication refrigerator of the Adult Unit.

2. Each of these vials were contained in their original manufacture's packaging without any pharmacy label. The vial of Lantus insulin was dispensed in a clear plastic bag containing a pharmacy label on the bag instead of the box or the container.

3. When questioned how he/she prevents medication administration errors since the pharmacy label was not permanently affixed to the medication container, Staff #21 confirmed that there should have been labels affixed to the medication containers.

4. These findings were confirmed by Staff #21.

Based on observation and staff interview conducted on 2/16/17, it was determined that the facility failed to ensure that unusable drugs are not available for patient use.

Findings include:

1. During an observation in the Adult Inpatient Unit Medication Room, Oxycontin 10 mg (milligram) tablets that were repackaged as unit dose in tamper evident packaging by the pharmacy department were found.

a. The back of the blister pack for two tablets were opened and had a yellow piece of paper taped to the back of the blister pack so that the tablets would not fall out.

2. During an observation in the Children and Adolescent Inpatient Services Unit Medication Room, Clonazepam 0.5 mg tablets that were repackaged as unit dose in tamper evident packaging by the pharmacy department were found.

a. The back of the blister pack for one tablet was opened and had tape over the opened blister pack to prevent the tablet from falling out.

3. Staff #21 stated that those should not have been there and should have been disposed of.

4. These findings were confirmed by Staff #21.

Based on observation, review of facility provided documents, and staff interview conducted on 2/16/17, it was determined that the facility failed to be in compliance with Federal and State licensure requirements for food and dietary personnel as well as food service standards, laws and regulations.


Findings include:

1. The facility failed to ensure that the Director of Food & Nutrition provides effective daily management of the Food Service Department in accordance with Federal, State and Local Regulations.
(Refer to Tags A620 and A631)

35697

A. Based on staff interview, document review, and review of facility policy and procedure, it was determined that the dietary services failed to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24).

Findings include:

Reference #1: The Manager retail operations- Grade 5 job description states, "... 1. Position Summary...Responsible for menu planning, food production and service; cash handling; staffing; and meeting all safety, sanitation and regulatory requirements. ...1. ...Assures compliance with all relevant health codes; regulatory and quality assurance requirements; safety and sanitation regulations and all policies are set forth by Rutgers University Dining Services. Identifies food services objectives and special problem areas and determines means by which objectives might be met and weakness eliminated...3. Staffing. Hires, trains and supervises of all employees assigned to the operation which includes, interviewing, hiring, job performance evaluation, payroll and all personnel-related activities. ..."

Reference #2: The facility document titled " Food safety Manual" states, "...Foodhandlers must be conscious of their actions and avoid the following when working with food: Eating or Drinking in the Food Preparation Areas...FOOD STORAGE..Storage practices and facilities are to provide quarters appropriate for the preservation of food quality and food safety. ...
* 'First In-First Out'
* Potentially Hazardous Foods must be stored below 40 degrees F or above 140 degrees F
* Store foods in areas designated for storage only
* Cover/Wrap foods in materials that are moisture proof and airtight * Identify all products with Delivery dates
* Storage areas are to be kept neat, clean, well lit, well ventilated, and in good repair. ...
Dry Storage
1. All containers of food are to be stored 4-6 inches above the floor, on clean surfaces, protected from splash, leakage, and other contamination. ...
Refrigerated Storage
2. All foods are to be stored off the floor, properly labeled and dated. ...
6. Refrigeration equipment shall be kept clean, in good working order, and equipped with a thermometer located in the warmest part of the unit. ...
Frozen Food Storage
3. Food containers/boxes dated with easy to read date of receipt in order to meet FIFO rule. Foods clearly identified with labels, and leftovers identified with date of entry into unit. ...
CLEANING & SANITIZATION
Test kits/test strips and a thermometer must be available to accurately measure parts per million and temperature of the sanitizing solution. ...

Reference #3: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #4: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #5: N.J.A.C. 8:24-3.2 states, "Food Packages: shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants."

Reference #6: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately measures the concentration in mg/L of sanitizing solutions shall be provided." 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #7: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."


1. During a tour of the Piscataway facility at approximately 11:15 AM, in the presence of Staff #3, the following deficient practices were observed in the kitchen area:

a. The pot washing area had a 3-compartment sink, which was used to clean fruit and vegetables and also for pot washing.

(i) The fruit and vegetable wash solution test strips had an expiry date of 6/2015.

(ii) The QUAT sanitizer strips that were being used to test the pot washing solution had an expiry date of 12/15/2013. (Refer to References #2 and #6)

b. The dishwasher had the incorrect detergent being used. Staff #3 immediately confirmed and removed the detergent container, and stated that the correct detergent was on order.
(Refer to References #2 and #4)

c. The dishwasher doors were visibly dirty with brown/orange and white stains.
(Refer to References #2 and #4)

(i) The dish drying rack contained aluminum baking trays, dish cover domes and three inch and six inch deep pans that were placed on top of each other while wet. Pots and pans were not placed in a position to air dry.

d. Refrigerator #8 had approximately 24 unlabelled eight (8) ounce cups of a cloudy liquid and brown liquid. During interview, Staff #3 stated that the cups contained vitamin water and iced tea. Staff #3 was unable to provide the date on which the liquids were prepared. (Refer to Reference #2)

e. Freezer #2, which was near the dry storage area contained the following:

(i) A 6 inch pan of salad with an expiry date of 1/16/2017.

(ii) Four (4) gluten free personal size pizza crust with no expiry date that appeared to have freezer burn.

(iii) Gluten free tortilla package with no expiry date and visible freezer burn.

(iv) One (1) box of Halal Hamburgers with no expiry date. (Refer to References #2 and #5)

f. Refrigerator #9, which was used to keep the tray line items, failed to have a thermometer.
(Refer to Reference #2)

g. A refrigerator, under the grill area, contained the following:

(i) Visible gray/black gaskets, which failed to seal the doors.

(ii) Many electrical wires visible near the stored food items inside the refrigerator.

(iii) Four (4) plates filled with wilted lettuce, covered with plastic wrap, with no label. (Refer to References #2, #3 and #4)

h. The walk in freezer next to the dry storage area, had an outside thermometer which had duct tape on it. Staff #3 stated that it had been broken ever since he/she had worked in the kitchen. (Refer to References #2, #3 and #4)

i. Refrigerator #1 had gaskets that were visibly full of debris and were frayed unable to make a seal on the door.

j. Refrigerator #2 had gaskets with visible debris and brown coloration. (Refer to References
#2, #3 and #4)

(i) Four (4) personal pan size pizza's were in Refrigerator #2 with no expiry date. (Refer to Reference #2)

2. Four (4) food handlers were observed with personal beverages in the food preparation area. (Refer to Reference #2)

3. The above findings were confirmed with Staff #1 and Staff #3.



37433


Monmouth Junction Outpatient and Partial Hospital
Cherry Hill Partial Hospital Program

B. Based on observation, document review and staff interview, it was determined that the facility staff failed to enforce the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24).

Findings include:

Reference #1: The facility document titled "Food safety Manual" states, "...FOOD STORAGE..Storage practices and facilities are to provide quarters appropriate for the preservation of food quality and food safety. ...
* Identify all products with Delivery dates
* Storage areas are to be kept neat, clean, well lit, well ventilated, and in good repair. ... Refrigerated Storage ... 2. All foods are to be stored off the floor, properly labeled and dated."...

Reference #2: N.J.A.C. 8:24-6.5(b) states, ..."The physical facilities shall be cleaned as often as necessary to keep them clean."...

1. A tour of the Kitchen at the Monmouth Junction Outpatient and Partial Hospital Site on 2/17/17 revealed the following:

a. A 4 pound opened jar of grape jelly with a sticker stating: "USE BY 1/31/16" was in the refrigerator.

2. A tour of the Pantry at the Monmouth Junction Outpatient and Partial Hospital Site on 2/17/17 revealed the following:

a. A large plastic bin on a shelf contained the following items:

(i) Two (2) opened bottles of ReaLemon lemon juice with a sticker stating: "USE BY 6/24/16." The manufacturers expiration date on both bottles was also 6/24/16.

(ii) One (1) opened box of Pure Baking Soda with a sticker stating: "USE BY 2/10/16."

(iii) One (1) opened plastic jug of honey without an expiration sticker.

(iv) One (1) opened box of Davis Baking Powder with a sticker stating: 'USE BY 2/30/16.

(v) One (1) opened jar of Adobo seasoning without an expiration sticker.

(vi) A Styrofoam cup containing a granular substance. There was no indication of the contents of the cup, no expiration sticker, or a lid on the cup.

b. A plastic bin on a shelf contained a four (4) expired bottles of Italian salad dressing.

c. On the shelf was one (1) unopened 4 pound jar of grape jelly with a sticker stating: "USE BY 12/19/16."

3. Upon tour of the Cherry Hill Partial Hospital Program Food Staging Room on 2/17/17, in the presence of Staff
#37 and Staff #38, the following was observed:

a. The utility sinks used for washing, rinsing and sanitizing dishes had visible dirt, debris and food particles throughout all of the sinks and on the surrounding wall surfaces. (Refer to Reference #2)

b. An open metal shelf in the Food Staging room contained the following as noted in Reference #1:

(i) A one (1) gallon container of Franks Red Hot sauce, was not labeled or dated.

(ii) A white squeeze bottle containing a red liquid substance, was not labeled or dated.

c. The refrigerator had the following findings:

(i) Two (2) large containers with yellow liquid, that were not labeled or dated.

(ii) Multiple large containers with salad dressing, were not dated.

(iii) One (1) large container of mayonnaise, was not dated.

(iv) Multiple containers of ketchup and mustard, that were not dated.

d. The above findings were confirmed by Staff #37.


38256

Reference #3: N.J.A.C. 8:24-4.11(e)(4) states, "Equipment, utensils, linens, single-service and single-use articles protection requirements shall include the following ... 4. Items that are kept in closed packages may be stored less than six inches above the floor on dollies, pallets, racks, and skids that are designed as specified under N.J.A.C. 8:24-4.2(s)."

1. During a tour of the facility Pantry Supply Room conducted on 2/17/17, the following supplies were observed to be stored directly on the floor:

a. Three (3) large boxes of disposable cups.

b. One (1) large box of disposable plates.

2. These findings were confirmed by Staff #37.

Based on observation and staff interview conducted on 2/16/17, it was determined that a current therapeutic diet manual was not readily available to all medical, nursing, and food service personnel.

Findings Include:

1. During interview, Staff #7 stated that the current diet manual is available in the dietary department only. Staff #7 further stated that there was no manual available on the patient care units.

2. The above findings were confirmed with Staff #1 and Staff #3.

Based on observation, interviews with administrative staff, review of policy and procedure, and review of related documentation, it was determined that the facility failed to be constructed and maintained to ensure the safety of patients and to provide facilities appropriate to the needs of the patient community.

Findings include:

1. The facility failed to ensure the overall hospital environment was maintained for the safety and well-being of the patients, staff, and public. (Refer to Tag A701)

2. The facility failed to maintain equipment to ensure an acceptable level of safety and quality. (Refer to Tag A724)

Based on observation and staff interview, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety and well-being of the patients, staff, and public.

Findings include:

1. A tour of the Adolescent and Children's Unit at the Piscataway Campus revealed:

a. Nurses Station:

(i) A pistachio shell, grit, dust, paper scraps, pens, a lollipop, paper clips were on the floor beneath a small black metal cabinet which was under the counter.

(ii) Another small black cabinet under the counter had dried stains, a pistachio shell, popcorn, Cheez-it pieces, a desiccated piece of apple, paper scraps, pens, dust, grit, a tacky yellow substance, and napkins on the floor beneath it.

(iii) A large black, metal cabinet had heavy dust, grit, staples, dried spillage, paper clips, and paper scraps on the floor beneath and behind it.

(iv) On the floor under the cabinet facing the hallway was observed pieces of cereal, dust, paper particles from a hole puncher, and grit.

(v) In the rear room, a black metal cabinet under the counter had pistachio shells, heavy dust, grit, pencils, dried spillage, paper scraps, and paper clips on the floor beneath it.

(vi)A pigeon hole bin on a counter had a heavy accumulation of dust atop it.

(vii) The front of a black metal cabinet near the entrance had heavy stains.

(viii) Another black metal cabinet beneath the counter had a heavy accumulation of dust atop it.

(ix) Black metal ledges and cabinets had tape and tape residue on them.

(x) Counters had tape and tape residue on them.

b. Nurses Station Back Room:

(i) A black metal cabinet beneath the counter had a heavy accumulation of dust atop it.

(ii) A recessed area of the counter top next to the wall had heavy dust, grit, hair, paper scraps, tape, tape residue, dried rubber bands, and other refuse in it.

(iii) Heavy dust was atop the wall cabinets.

c. Medication Room:

(i) Heavy dust, a dusty cloth bag, clumps of dust, grit, paper scraps, and a paper bag was observed on the floor beneath and behind a raw wood stand supporting a refrigerator.

(ii) A cabinet under the counter had raised brownish-red stains in the back corner, dried spillage on the sides and bottom shelf, and tape and tape residue on the shelves.

(iii) Heavy dust was on the counter beneath and behind the copier.

(iv) Three drawers had grit, dust, and paper scraps inside of them.

(v) A refrigerator was set atop a raw wood stand. Raw wood is an uncleanable surface. There was heavy dust on the raw wood stand.

(vi) A cabinet beneath the sink contained a bar of soap stuck to a wash cloth, a plastic container with rotting food inside of it, a black mold-like substance on the outside of the container, and spillage from the container.

d. Dining Room:

(i) Dust, grit, dried spillage, and paper scraps were on the floor beneath and behind the refrigerator.

(ii) Heavy dust was atop wall cabinets.

(iii) Plastic bins inside the bottom of the refrigerator had grit and dried spillage inside of them. There was tape on the exterior of the refrigerator.

(iv) A piece of raw plywood was screwed to the wall behind a cabinet. Raw wood is an uncleanable surface.

e. Laundry Room:

(i) The floor beneath and behind a black metal cabinet had rust stains, rust particulate, grit, dried white particulate, dust, a pencil, and a toothpick on it.

(ii) A black metal cabinet had a heavy accumulation of dust on the bottom shelf and on the exterior.

f. Sensory Room: Hair, dust, grit, paper scraps, and Styrofoam pellets were observed on the floor.

g. Classroom: In the computer room there were dead bugs atop the light cover.

2. A tour of the Acute Psychiatric Services Unit at the Piscataway Campus revealed:

a. Nurses Station:

(i) Black, rubber base molding near the gate was held to the wall with surgical tape. The tape had an accumulation of dust, grit, and hair on it.

(ii) A wall outlet near the gate had a dried foodlike substance on it.

(iii) There was an accumulation of heavy dust on the shelves beneath the video monitor.

(iv) A surge protector had a heavy accumulation of dust, grit, spillage, and surgical tape on it.

(v) A rolling metal cabinet had grit, dust, paper scraps, and food particles in the bottom drawer.

b. The Storage Room had an accumulation of dead bugs on the floor.

c. Room B138A (Patient Storage Room): there were areas of chipping paint and unpainted patches of joint compound.

d. The walls in the bathroom had chipped paint and exposed particle board.

e. Screener Office:

(i) There was a heavy accumulation of dust, grit, paper clips, and refuse beneath a metal grill on the counter top.

(ii) A portable air purifier had an accumulation of dust on the grill.

(iii) There was heavy dust on the counter behind the computer monitor screen, atop the frame, and on the metal rod attached to the wall next to the large monitor.

(iv) There was heavy dust, grit, paper scraps, and a large desiccated bug on the floor.

(v) A white rolling cabinet beneath the counter had electrical tape affixed to a broken drawer. There was dust and grit stuck to the tape.

3. There were dead bugs atop a light cover outside of the First Floor elevators in the Piscataway Campus.

4. A tour of the Monmouth Junction Outpatient and Partial Hospital Site on 2/17/17 revealed:

a. Kitchen:

(i) Dust and grit were observed on the floor. Areas of the floor were greasy.

(ii) There were missing floor tiles and gaps between tiles.

b. Dining Hall:

(i) A paperback book with a heavy coat of dust was on the floor behind a tall, black, metal cabinet.

(ii) There was heavy dust atop the Coke vending machine.

(iii) There was heavy dust and dirt atop a tall gray metal cabinet. The bottom interior of the cabinet was very rusty.

(iv) A condiment container and a napkin holder were stuck to a table with a sticky substance. Beneath the the stuck items were ground coffee particles and a sugar-like particles. Inside of the condiment container were opened packets of Sweet N Low and a white powdery substance at the bottom of the container.

(v) There was heavy scale on the stainless steel top of the coffee machine where water is poured in.

(vi) Two desiccated bugs were on the floor near the wall separating the Kitchen form the Dining Room.

(vii) There was a cabinet with a black substance on the bottom shelf. The back of the cabinet frame was unfinished particle board, an uncleanable surface.

c. Treatment Room: there was a heavy accumulation of dust behind a printer set atop a rolling cabinet and on the top of the cabinet. A surge protector atop a desk had a heavy accumulation of dust and a piece of clear tape that had heavy dust, hair, and grit stuck to it.

d. Medication Room: There was a green substance in the rear interior of the medication refrigerator.

e. Group Room 22: There was a potted plant on the floor in the corner of the room and spilt dirt, dried stains, grit, and dust on the floor. There were cobwebs in the corner behind the door and a small bug crawling on the floor.

f. Group Room 20: There were stains, dust, and grit on the floor in the corners of the room and against the walls.




13896


5. On 2/15/17, during a tour of the AIPU on the Piscataway Campus, in the presence of Staff #59 the following was observed:

a. In Room B243A, the caulk around the bath tub had a mildew-like-substance and within the tub there was a dark residue. The wall paint was chipped.

b. In Room B255A, the shower floor had mildew-like stains. The wall paint was chipped. The ceiling vent was rusty.

c. In the Laundry Room, lint was on the floor, on the wall and on the cart.

d. In the Treatment Room, the faucet had green residue, and the sink was stained.


33556


6. During a tour of Piscataway Campus conducted at 10:30 AM on 2/16/17, in the presence of Staff #57, the following were noted:

a. Stained or discolored ceiling tiles were found in the following areas:

(i) Inside adult washer room #B-269.

(ii) Within the kitchen storage room adjacent to the exterior wall and windows.

(iii) In medication prep room #B-267.

b. Emergency eyewash stations which were visibly dirty with no record of recent maintenance or inspection in the following areas:

(i) Inside the D Building mechanical room.

(ii) Within D Building housekeeping laundry area.

c. The above findings were confirmed by Staff #57.




37433


7. During a tour of the Cherry Hill Partial Hospital Facility on 2/17/17 the following were observed:

a. The lobby waiting room contained three fabric covered chairs. Two (2) of the three (3) chairs had visible stains on the seats. All three (3) chairs had non cleanable surfaces.

b. Walls throughout the facility had visible, dirt, scuff marks and peeled paint down to the wall board.

c. Floors throughout the facility had visible dirt, and scuff marks that were in need of terminal cleaning.

d. In the female bathroom, used by both staff and patients, the walls were visibly dirty throughout the bathroom;
all toilets were visibly dirty in and around the toilet bowels; there was an unpleasant odor present upon entry into the bathroom.

e. The above findings were confirmed by Staff #37.




38256


8. During a tour of the Lunch Room at the Cherry Hill - Partial Hospital Facility conducted on 2/17/17 the following was observed:

a. The tables had brown build-up of grime, coffee stains and food particles.

b. Two (2) microwave ovens at the back of the lunch room had visible dirt, grime and dried food particles.

c. The floors had visible dirt, dust, scuff marks and food debris.

d. The above findings were confirmed by Staff #37.

A. Based on observation, it was determined that supplies are not maintained to ensure an acceptable level of safety and quality.

Findings include:

1. A tour of the Adolescent and Children's Unit at the Piscataway Campus revealed:

a. Medication Room: A cabinet contained a 3ml syringe with needle in an opened wrapper.

2. A tour of the CCIS (Children Intervention Services Area) Unit at the Piscataway Campus revealed:

a. Triage Room:

(i) A wall cabinet contained one (1) Sterile Suture Removal Tray with an expiration date of 1/1/15.

(ii) In a cabinet was an open plastic bag with a white sticky substance on it containing a nasal
cannula.

3. A tour of the Monmouth Junction Outpatient and Partial Hospital Site on 2/17/17 revealed:

a. Treatment Room:

(i) A gauze pad was in an opened package.

(ii) An eye pad was in a package with an expiration date of 2016-04 (4/30/16).



33800



4. During a tour of the Latency and Adolescent Unit at the Piscataway Campus on 2/16/17, in the presence of Staff #4, the following were observed:

a. The floors in Room #A259 contained holes and scratches.

b. The floors in the Sensory Room (Room #A252) contained scuff marks and were littered with dust, and balls of white and black-colored debris.

c. The floors in Room #A245 contained holes.

d. The walls in Room #A245 contained scratches.

e. The walls in Room #A247 contained scratches and the paint was peeled off.

f. The floors in Room #A249 were marred and contained debris.

g. The Day Room walls contained surfaces with peeled paint and the corners contained marred surfaces.

h. The doors in Rooms #A241 and #A241E contained scratches and gouges.

i. The above findings were confirmed with Staff #4.

5. During a tour of the Adult Unit on 2/16/17, in the presence of Staff #4, the following were observed:

a. The Nurses station (Room #B265) contained scratched and marred surfaces.

b. The windows in Room #B249 and Room #B251 contained a layer of dust.

c. A picture frame on the wall in Room #B236 contained a thick layer of dust.

d. In the bathroom in Room #B243, the area around the bathtub contained black stains and the ceiling contained peeling paint.

e. The windows in Room #B243 contained a layer of dust.

f. A pillow in Room #B245 contained cracks and tears, the windows contained a layer of dust, and the picture frame on the wall contained a thick layer of dust.

g. The heater in Room #B233 contained a thick layer of dust, and was littered with two medicine cups containing petroleum jelly.

(i) The room was currently vacant according to Staff #4. He/she stated, "Housekeeping forgot to pick it up."

h. The above findings were confirmed with Staff #4.

6. During a tour of the Edison site on 2//17/17, in the presence of Staff #2 , Staff #49, Staff #51 and Staff #52, the following were observed:

a. The floor in the "Xerox Room" was marred and contained black and gray residues.

(i) Staff #51 stated, "(The floors) are tarnished and scuffed up."

b. The men's bathroom contained black residue around the toilet bowl and the sink contained missing laminate on its surface.

c. The women's bathroom contained yellowish-white and black residue around the toilet bowl.

d. In the Staff Lounge, the counter around the sink contained laminate surfaces that were lifted and peeling; the corners of the counter contained missing laminates. The paint on a corner wall was peeled off. The dishwasher contained a thick layer of grayish-whitish residues.

e. The Storage Room floor contained a large amount of debris.

f. These findings were confirmed with Staff #2, Staff #49, Staff #51 and Staff #52.

7. During a tour of the Edison site on 2/17/17, in the presence of Staff #2 , Staff #49, Staff
#51 and Staff #52, the following were observed:

a. At 9:40 AM, the AED [automated external defibrillator] storage box was observed mounted on the wall. Upon further inspection, the "Zoll Pedipadz II" pediatric defibrillator pads contained in the AED storage box was labeled, "exp 2016-07-12."

(i) Staff #51 and Staff #52 stated that the facility did not have an alternate pediatric pad available onsite for its AED.

(ii) A review of the AED weekly monitoring log indicated that the supplies were inspected weekly from 11/21/16 to 2/9/17.

b. This finding was confirmed with Staff #2 , Staff #49, Staff #51 and Staff #52.

8. During a tour of the Storage Room at the Edison site, in the presence of Staff #2 , Staff #49, Staff #51, the following were observed:

a. The Biomed inspection sticker for the Medications Refrigerator indicated, "9/23/14."

b. The Biomed inspection sticker for the Lab Specimen Refrigerator indicated, "8/8/05."

9. At 9:57 AM in "Med Room #23" at the Edison site, in the presence of Staff #2, Staff #49, and Staff #51, the room thermometer indicated a temperature that was out of range, 50 degrees F. The log indicates the acceptable temperature range as, "36-40 degrees."



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Reference #1: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #2: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."


1. During a tour of the facility at approximately 11:15 AM, in the presence of Staff #3, the following deficient practices were observed in the kitchen area at the Piscataway Campus:

a. The entrance door to the kitchen area from the cafeteria had (2) two broken tiles right in the doorway threshold.

b. The door jam sweep of the entrance door into the kitchen from the cafeteria was visibly full of dirt and debris.

c. The trash cans in the cafeteria area, three (3) of them had lids visibly with food stains of multiple colors and were full to the top.

(i) During interview, Staff #3 stated that the cleaning of the cafeteria portion is the responsibility of the housekeeping department.

2. The floors throughout the kitchen area appeared visibly filled with dirt and debris.

3. The above findings were confirmed with Staff #3 and Staff #4.



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4. During a tour of the Cherry Hill Partial Hospital Program in the Food Staging room on 2/17/17, multiple coffee pots were observed.

a. The glass pots had a build up of brown and black residue, with a cloudy appearance on the glass.

5. This was confirmed with Staff #37 and Staff #38.



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B. Based on observation and interview with administrative staff, it was determined that the facility failed to ensure that floors and walls are free of signs of disrepair.

Findings include:

1. A tour of the Cherry Hill Partial-Hospital Facility, conducted on 2/17/17 revealed the following:

a. In the Lunch Room, a blue plastic-like border between the column and floor was noted to be peeling off the wall exposing dry wall.

b. In Room #158 and Room #166, floor tiles were separated from the walls and floor.

2. These findings were confirmed with Staff #37.

Based on observation, staff interview, and document review conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure that a sanitary environment was provided to avoid sources and transmission of infections and communicable diseases.

Findings include:

1. The facility failed to ensure implementation of hand hygiene in accordance with nationally recognized guidelines and its own policy and procedure. (Refer to Tag A748)

2. The facility failed to ensure a sanitary hospital environment is maintained. (Refer to Tag A749)

3. The facility failed to ensure manufacturer's instructions for use (IFUs) for its disinfectants are followed. (Refer to Tag A748)

4. The facility failed to ensure compliance with CDC guidelines for preventing transmission of M. tuberculosis. (Refer to Tag A749)

A. Based on observation, facility documentation review and staff interview conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure implementation of hand hygiene in accordance with nationally recognized guidelines and its own policy and procedure.

Findings include:

Reference #1: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states,
"Recommendations:
1. Indications for Handwashing and Hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1 C-J
C. Decontaminate hands before having direct contact with patients
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter.
E. Decontaminate hands before inserting...peripheral vascular catheters, or other invasive devices that do not require a surgical procedure
F. Decontaminate hands after contact with a patient's intact skin...
G. Decontaminate hands after contact with ... a patient's nonintact skin
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
J. Decontaminate hands after removing gloves. ..."

Reference #2: Facility policy and procedure titled, "Hand Hygiene" states,"... Procedure: 1. Indications for handwashing and hand antisepsis ... C. Decontaminate hands before having direct contact with patients ... 2. Hand-hygiene technique ... B. When washing hands with soap and water, wet hands first with water, apply a nickel sized puddle of pink antimicrobial soap as found in UBHC wall mounted soap units to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. ..."

1. A tour of the Laboratory was conducted in the presence of Staff #4 and Staff #13. Staff #14 was observed preparing to wash his/her hands before starting his/her shift.

a. When questioned about the facility's policy and procedure for Hand Hygiene, Staff #14 correctly stated, "15 seconds."

b. At 10:48 AM, Staff #14 was observed washing his/her hands for less than 8 seconds.

c. This finding was confirmed with Staff #4.

2. During observation of "Med Pass" medications administration in the Adult Unit, in the presence of Staff #4, the following were observed:

a. At 2:05 PM, Staff #29 performed hand washing for less than 5 seconds.

b. At 2:11 PM, Staff #30 was observed to administer medications without first sanitizing his/her hands.

c. These findings were confirmed with Staff #4.

B. Based on observation, facility documentation review, and staff interviews conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure that its personnel are trained and knowledgeable in Infection Control.

Findings include:

Reference: Facility policy and procedure titled, "Infection Control Plan" states, "... Prevention ... Our major preventive thrust is in the area of education. All employees receive an orientation to department specific infection control policies and procedures at hiring. Each employee is provided an update on any changes in policy and procedure and annual training in Bloodborne Pathogen and Standard Precautions."

1. During a tour of the Laboratory between 10:40 AM and 10:45 AM, in the presence of Staff #4, Staff #13 and Staff #14 were questioned regarding the content of their Annual Infection Control training.

a. Both were unable to state what was included in their Annual Infection Control training.

b. This finding was confirmed with Staff #4.

2. During a review of personnel employee records, in the presence of Staff #2, the files for Staff #4, Staff #13, Staff #14, Staff 27, Staff #28, Staff #31, Staff #32, Staff #33, Staff #34 lacked evidence of an Annual Infection Control training.

a. These findings were confirmed with Staff #2.

C. Based on observation, facility documentation review and staff interview conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure that manufacturer's instructions for use (IFUs) for its disinfectants are followed.

Findings include:

Reference #1: Reference: CDC [Centers for Disease Control and Prevention] Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 page 84 states, "Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. ... By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability from any injuries resulting from the off-label use and is potentially subject to enforcement action under FIFRA."

Reference #2: Accu-Chek Inform II glucometer manufacturer's IFU states, "... Acceptable Cleaning/ Disinfecting Agents ...Acceptable active ingredients and products for cleaning and disinfecting are: -Clorox Germicidal Wipes (EPA reg. no. 67619-12) ... -Super Sani-Cloth Germicidal Disposable Wipes (EPA reg. no. 9480-4) ... Always use Clorox Germicidal Wipes (EPA reg. no. 67619-12) and Super Sani-Cloth Germicidal Disposable Wipes (EPA reg. no. 9480-4) to clean and disinfect the meter. Do not use any other cleaning or disinfecting solution. Using solutions other than Clorox Germicidal Wipes (EPA reg. no. 67619-12) and Super Sani-Cloth Germicidal Disposable Wipes (EPA reg. no. 9480-4) could result in damage to the system components."

1. During an interview in Treatment Room #B242, in the presence of Staff #4, Staff #18 was questioned about the process of cleaning the Accu-Chek Inform II glucometer.

a. Staff #18 stated, "We use an alcohol wipe to clean them." He/she then presented the surveyor with a box labeled "Covidien alcohol prep 2-ply wipes Ref #5750."

b. The glucometer manufacturer's instructions for use were requested and received. Upon review, the IFU did not indicate alcohol prep wipes as an acceptable cleaning and disinfecting agent for use with this glucometer.

c. The facility failed to ensure that the manufacturer's cleaning and disinfecting instructions were followed.

d. This finding was confirmed with Staff #4.

2. During observation of a Med Pass medication administration in the Adult Unit at 2:05 PM, in the presence of Staff #4, Staff #29 was questioned about the process of cleaning the Accu-Chek Inform II glucometer.

a. He/she stated, "We use alcohol wipes for cleaning the glucometer."

b. The facility failed to ensure that the manufacturer's cleaning and disinfecting instructions were followed.

c. This finding was confirmed with Staff #4.

3. During a tour of the Edison site on 2/17/17, in the presence of Staff #2 and Staff #49, Diversey Oxivir disinfectant solution and the Dispatch towelettes with Bleach were observed in the room. Staff #53 was questioned regarding the use of the Diversey Oxivir disinfectant solution and the Dispatch towelettes with Bleach.

a. Staff #53 stated, "I don't know instructions. I just do as I do."

4. A Welch Allyn BP [blood pressure] cuff was observed on a counter.

a. The manufacturer's IFU for the Welch Allyn BP cuffs were requested and not received.

(i) Staff #53 stated, "I don't have (IFU)."

b. Staff #53 was questioned by this surveyor how he/she cleans the BP cuffs. He/she answered, "I use (points to Dispatch towelettes with Bleach) to clean."

5. The facility failed to ensure manufacturer's IFUs are available at the point of use.

6. The facility failed to ensure all personnel responsible for the use of disinfectants are knowledgeable on the manufacturer's label instructions.

7. The facility failed to ensure all personnel responsible for the cleaning and disinfecting reusable patient care devices are knowledgeable on the manufacturer's IFUs.

8. These findings were confirmed with Staff #2 and Staff #49.




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D. Based on observation and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment.

Findings:

1. Upon tour of the Cherry Hill Partial Hospital Program Food Staging room on 2/17/17, the following were noted:

a. A large brown container for food transport received from Rutgers Dining was observed.

(i) Staff #38 was unable to produce the instruction for use (IFU) and was not aware of the approved cleaning agent and protocol.

b. Staff #38 was unaware of any approved cleaning agents for the food staging area, and was unable to produce any IFU.

2. The above was confirmed with Staff #37.

A. Based on observation, facility documentation review and staff interviews conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure that a sanitary environment is provided, and infection control practices that adhere to nationally recognized infection control guidelines are implemented.

Findings include:

Reference #1: ANSI/AAMI ST 79 "Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities" (2013) section 8.9.2 states, "Sterile items should be stored in a manner that reduces the potential for contamination. ... The items should be positioned so that the packaging is not crushed, bent, compressed, or punctured and so that their sterility is not otherwise compromised. Medical and surgical items, including those packaged in rigid sterilization container systems, should not be stored next to or under sinks, under exposed water or sewer pipes, or any location where they could become wet. Supplies should not be stored on floors, on windowsills, or in areas other than designated shelving, counters or carts. ..."

Reference #2: AORN Guidelines For Perioperative Practice, 2016 edition Recommendation XV pages 838-839 states, "Sterilized materials should be labeled and stored in a manner to ensure sterility ... XV.b.5. Supplies should be stored in a manner that allows adequate air circulation and ease of cleaning in compliance with local fire codes and in a manner that reduces the risk of contamination. "

1. During a tour of the Edison site on 2/17/17, in the presence of Staff #2, Staff #49, and Staff #53, sterile 21-gauge needle filters were observed to be crushed and compressed together with rubber bands around them.

a. This manner of storing the sterile items increases the potential for contamination.

2. This finding was confirmed with Staff #2, Staff #49 and Staff #53.

B. Based on observation, facility documentation review and staff interviews conducted on 2/16/17 and 2/17/17, it was determined that the facility failed to ensure compliance with CDC guidelines for preventing transmission of M. tuberculosis.

Findings include:

Reference: CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, published in the Morbidity and Mortality Weekly Report at MMWR 2005; 54 (No. RR-17) states, "All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. After baseline testing for infection with M. tuberculosis, HCWs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCWs with baseline negative test results). HCWs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit. "

1. Upon review of employee health files, in the presence of Staff #2, the following findings were revealed:

a. Staff #4's file lacked evidence of annual TB screening in 2010, 2012, 2014, and 2015.

b. Staff #14's file lacked evidence of annual TB screening in 2009, 2010, 2012, 2014, 2015, and 2016.

c. These findings were confirmed with Staff #2.





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C. Based on observation, review of facility documentation and staff interview, it was determined that the facility failed to follow CDC guidelines when monitoring and recording vaccine storage.

Findings:

Reference #1: The Center for Disease Control website titled "Epidemiology and Prevention of Vaccine-Preventable Diseases," states, "CDC recommends reviewing and recording temperatures in both the freezer and refrigerator units at least 2 times each workday, in the morning and before leaving at the end of the workday."

1. Upon a tour of the Cherry Hill Partial Hospital Program Room #153 on 2/17/17, two (2) boxes of ten (10) Flu vaccines were found in the medication refrigerator.

2. Staff #39 confirmed that monitoring of the Flu Vaccine refrigerator only occurs once daily.

3. Above confirmed with Staff #37, Staff #39 and Staff #40.

Based on review of one of two medical records of patients receiving outpatient services and staff interview, it was determined that the facility failed to ensure that the non adherence to treatment policy is implemented.

Findings include:

Reference: Facility policy "Non-Adherence to Treatment" stated, " ... Definitions

1. Treatment non-attendance includes but is not limited to:
a. Failing to show for a scheduled appointment
b. Cancellation of a scheduled appointment less than 24 hours prior to the appointment (to be documented as a "no-show") ...
3. Non-adherence to therapy regimes includes but is not limited to:
a. Consistent refusal to accept therapeutic interventions that have been recommended by the treatment team.
b. Cancellation on non-attendance at more than 25% of scheduled therapy appointments ...

Policy
1. Every effort will be made to educate and motivate clients to follow the treatment plan recommended by the treatment team ...
2. When any member of the treatment team becomes aware on non-adherence, the entire team will address this issue.

Procedure
A. Treatment non-attendance
After a client fails to show for a scheduled appointment or cancels with less than 24 hours notice, the following will occur:
1. If no risk factors are present, letters will be sent to the client in the following fashion:
a. After a missed appointment, a notification letter will be sent to the client ...
b. A termination letter will be sent via certified mail with a return receipt requested if the client does not reschedule an appointment within two weeks after the missed appointment or doesn't show for a rescheduled appointment ..."

1. The medical record of Patient #19 indicated that the patient was attending outpatient services. The Pharmacological Management Progress Notes dated 8/22/16, 9/19/16, 10/13/16 indicated for the patient to return in two weeks; the progress note of 12/8/16 to return in 6 weeks and the note of 12/30/16 to return in one week. The patient presented for an unscheduled appointment on 2/8/17. In addition, the patient was to "continue talk therapy with __ [name of therapist]." The patient was non compliant with the plan of care.

a. There was no evidence that letters were sent to the patient from 8/22/16 to 2/8/17. There was no evidence that the treatment team had discussed with the patient the non-adherence to treatment issue.

b. The above was confirmed with Staff #58.

Based on medical record review and staff interview it was determined that the Psychosocial Assessments for six (6) of eight (8) patients (Patients A1, A2, B1, B2, B3 and B4) failed to include a description of the anticipated social service staff role in discharge planning. This failure results in no information for the other members of the multidisciplinary treatment team about what the social service staff may be pursuing toward discharge planning.

Findings include:

A. Medical Record Review:

1. Patient A1: The Psychosocial Assessment, dated 2/7/17, had no description of what the social service staff's anticipated efforts toward discharge planning would be.

2. Patient A2: The Psychosocial Assessment, dated 2/10/17, stated "Pt (patient) will be linked to OP (Outpatient) resources that can best meet his/her needs upon D/C (Discharge)."

3. Patient B1: The Psychosocial Assessment, dated 2/8/17, had no description of what the social service staff's anticipated efforts toward discharge planning would be.

4. Patient B2: The Psychosocial Assessment, dated 2/1/17, had no description of what the social service staff's anticipated efforts toward discharge planning would be.

5. Patient B3: The Psychosocial Assessment, dated 1/7/17, stated "Patient B3 would benefit from the structured milieu environment where he/she can interact with peers supported by staff..." No description of the anticipated role of the social service staff was described in effecting that outcome.

6. Patient B4: The Psychosocial Assessment, dated 2/11/17, stated "Treatment team will utilize a discharge plan that connects Patient B4 to the appropriate level of psychiatric/therapeutic services following discharge."


B. Staff Interview:

On 2/16/17 at 8:55 a.m., the Director of Social Service was interviewed by the surveyors. The Director was told of the findings described in Section A above, and was asked to examine the Psychosocial Assessments of Patients A1, A2 and B2. The Director agreed that there was not present a description of the anticipated role of social service staff in discharge planning.

Based on medical record review and staff interview it was determined that eight (8) of eight (8) Psychiatric Evaluations failed to include an assessment of patient assets in descriptive not interpretive fashion. This failure results in no information about patient interests, accomplishments, goals etc. that might possibly be utilized in the selection of treatment modalities.

Findings include:

A. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation, dated 2/7/17, stated as the sole patient asset "Pt. (patient) is voluntary for inpt (in-patient) hospitalization."

2. Patient A2: The Psychiatric Evaluation, dated 2/8/17, stated as the only patient asset "Voluntary."

3. Patient A3: The Psychiatric Evaluation, dated 1/10/17, stated as the only patient asset "Voluntary."

4. Patient A4: The Psychiatric Evaluation, dated 2/10/17, stated as the only patient asset "Pt. is voluntary for inpt treatment."

5. Patient B1: The Psychiatric Evaluation, dated 2/7/17, stated as the patient's sole asset "Mother is support."

6. Patient B2: The Psychiatric Evaluation, dated 2/1/17, stated as the sole patient asset "Patient has a supportive family."

7. Patient B3: The Psychiatric Evaluation, dated 1/5/17, stated for the patient's assets "Patient is articulate."

8. Patient B4: The Psychiatric Evaluation, dated 2/10/17, stated as the patient asset "Patient is talkative."


B. Staff Interview:

On 2/17/17 at 9:15 a.m., the clinical director was interviewed. The findings described in Section A above were discussed. The clinical director agreed that the statements were not inherent patient assets stated in descriptive not interpretive fashion.