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Based on record review and interview the hospital failed to include identified patient care issues in their Quality Assurance/Performance Improvement Program as evidenced by the failure to monitor Patient Master Treatment Plans resulting in 1) continued non-compliance of measurable short and long term goals (#F4, #F5, #F6, #F7); 2) failure to record patient progress (#F4, #F5, #F6, #F7); and 3) failure to provide social service activities as stated in the Master Treatment Plan (#F4, #F5, #F6, F#7). Findings:

1) Continued non-compliance of measurable short and long term goals (See findings at Tag B0121);

2) Failure to record patient progress (See findings at Tag B0123); and

3) Failure to provide social service activities as stated in the Master Treatment Plan (See findings at Tag B0131).

Based on record review and interview the hospital failed to ensure data had been collected, analyzed and corrective action implemented for identified problems related to patients' individualized Master Treatment Plans resulting in failure to provide feedback and learning to staff and continued non-compliance in implementation of the treatment plans. Findings:

Review of the "Administrative Executive Leadership Benchmarks" submitted by SF1, Director of Nursing (DON), revealed no documented evidence indicators were developed to monitor identified problems related to Master Treatment Plans. Further review revealed no documented evidence data had been collected, trended, and/or corrective action taken related to the identified problems in the Master Treatment Plans.

In a face to face interview on 10/06/10 at 11:00am SF1, DON verfied chart checks were implemented on 10/01/10 and did not include monitoring of measurable goals, recording progress of the patient in the treatment plan, or implementing changes in the treatment plan. Further she indicated because the audits had just begun, no information had been provided to the staff.




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Based on record review an interview the hospital failed to ensure all identified patient care issues were included in their Quality Assurance/Performance Improvement Program as evidenced by the failure to monitor Patient Master Treatment Plans resulting in 1) continued non-compliance of measurable short and long term goals (#F4, #F5, #F6, #F7); 2) failure to record patient progress (#F4, #F5, #F6, #F7); and 3) failure to provide social service activities as stated in the Master Treatment Plan (#F4, #F5, #F6, F#7). Findings:

1) Continued non-compliance of measurable short and long term goals (See findings at Tag B0121);

2) Failure to record patient progress (See findings at Tag B0123); and

3) Failure to provide social service activities as stated in the Master Treatment Plan (See findings at Tag B0131).




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Based on record review and interview the hospital failed to ensure a Registered Nurse, SF3, was credentialed according to medical staff bylaws to dictate, coordinate, and complete physician ' s discharge summaries by: 1. Failing to ensure the Registered nurse obtained letters of recommendation according to the medical staff bylaws and 2. Failing to ensure the Registered Nurse had professional liability insurance as specified by the Medical Staff Bylaws. Findings:
Review of the medical staff bylaws revealed, in part, " Approved Allied Health Professional Disciplines: Physician ' s Assistant, Nurse Practitioner, Psychologist, and Registered Nurse. " Further review revealed, in part, " Credentialing- Applications from Allied Health Professionals shall be processed in accordance with the credentialing procedures used for practitioners, except that at least two (2) of the three (3) required letters of recommendation must be from Practitioners " . Further review revealed, in part, " Qualifications- Professional Liability Insurance " . Further review of the Medical Staff Application Requirements revealed, in part, " Evidence of professional liability insurance with a minimum of $1,000,000 per claim/$3,000,000 aggregate from a company that has a A-rating or better from a selected national insurance rating agency " .
Review of SF3, RN ' s personnel file revealed, " Delineation of Privileges Registered Nurse- Scope of Privileges for a Registered Nurse to include: 1. The registered nurse can gather data, coordinate, and dictate discharge summaries " ...
Review of SF3, RN ' s personnel file revealed the 3 letters of recommendation were submitted by registered nurses and not practitioners. On 10/05/10 at 10:30 a.m. SF1, Director of Nursing, confirmed that 2 of the 3 required letters of recommendation were not completed by practitioners.
Review of SF3, RN ' s personnel file revealed no documented evidence of professional liability insurance. On 10/05/10 at 10:30 a.m. SF1, Director of Nursing, confirmed that the hospital failed to ensure SF3, RN, had professional liability insurance as required by the medical staff bylaws.

Based on record review and interview the hospital failed to meet the Condition of Participation for Special Medical Records requirements for Psychiatric Hospitals by:

1) Failing to ensure the patients' Master Treatment Plan included measurable short-term and long-term goals for 4 of 4 patients with the Master Treatment Plan newly implemented by the hospital out of a total sample of 8 patients (#F4, #F5, #F6, # F7) (See findings at Tag B0121);

2) Failing to ensure social services performed their assigned interventions specified in the patient's plan of care (Master Treatment Plan) for 4 of 4 patients reviewed for Treatment Planning in a total sample of 8 patients (#F4, #F5, #F6, #F7) (See findings at Tag B0123);

3) Failing to ensure the medical record of patients contained documentation of the intensity of the treatment, effects of the interventions, and outcomes experienced as evidenced by no documented evidence for changes made in the treatment plans, no documented evidence treatment plan meetings had been performed or that the ordered interventions had been performed for 4 of 4 patients admitted to the facility using the newly developed Daily Treatment Plan Update and Team Progress Note out of a total sample of 8 patients (#F4, #F5, #F6, #F7). (See findings at Tag B0131)

Based on record review and interview the hospital failed to ensure the patient's written plan of care (Master Treatment Plan) included short-term and long-term goals that were written in a way that would allow changes in the patient's behavior to be measured for 4 of 4 patients with the revised Master Treatment Plan which included short and long term goals reviewed for treatment planning out of a total sample of 8 patients (#F4, #F5, #F6, # F7).
Findings:

Patient #F4
Review of the medical record for Patient #F4 revealed she was admitted to the hospital on 09/24/10 with the diagnosis of schizoaffective disorder. Review of Patient #F4's Master Treatment Plan revealed the following:
Problem #1: Impulse Control and Labile Mood
Short-term Goals: Patient will demonstrate improved self-control
Long-term Goals: Significantly decrease the frequency of impulsive acts
Further review revealed no documented evidence defining measurable parameters which would be considered a significant decrease and an improvement in behaviors (frequency, intensity, etc) in order for the treatment team to assess achievement of goals.
Problem #2: Legal Problems
Short-term Goal: To appear in court October 06, 2010 at 3:00pm
Long-term Goal: To avoid legal problems at home and in social settings
Further review revealed the only intervention was to provide and coordinate transportation to court by Social Services.
Problem #3: Discharge Planning
Short-term Goal: Find a family member that will agree to live with patient
Long-term Goal: Stable living environment that is safe
Further review revealed family sessions to establish a safe environment were to be conducted by Social Services; however there was no documented evidence any family sessions had been conducted.

Patient #F5
Review of Patient #F5's Master Treatment Plan revealed the following:
Problem #1: Depressed Mood
Short term goals: no suicidal ideation, improved mood, improved socialization through group therapy, coping skills training, improved sleep.
Long term goals: stabilization of psychiatric features.
Further review revealed the hospital failed to specify the frequency that the patient would be assessed for exhibiting suicidal ideations, mood changes, socialization problems, difficulty with coping, or sleep patterns. The hospital failed to specify how they would measure any improvements the patient would have with the above identified problems. Further the hospital failed to indicate a date of which the patient would achieve the above goals.

Patient #F6
Review of the medical record for Patient #F6 revealed he was admitted to the hospital on 09/23/10 with the diagnosis of schizoaffective disorder. Review of the Master Treatment Plan revealed the following:
Problem #1: Anger and Threatening Behavior
Short-term Goals: Help patient identify the fears, hurt and alienation that others experience as a result of his anger
Long-term Goals: The ability to recognize and appropriately explain angry feelings as they occur. Further review revealed no documented evidence how the hospital would assess and measure the goals for improvement.

Patient #F7
Patient #F7 was admitted to the hospital on 10/01/10 with a diagnosis that included vascular dementia secondary to cerebral vascular accident, depression, and psychosis.
Review of Patient #F7's Master Treatment Plan revealed the following:
Problem #1: Aggressive and Threatening behavior manifested by swinging chair at staff and cursing.
Short Term goals: reassure and attempt to provide decrease in paranoia, de-escalation of moods and anxiety.
Long Term goals: Significantly decrease the frequency of aggressive behavior.
Further review revealed the hospital failed to specify the frequency that the patient would be assessed for aggressive and threatening behaviors. The hospital also failed to specify how they would measure a decrease in the patient's aggressive behavior. Further the hospital failed to indicate a date of which the patient would achieve the above goals.

In a face to face interview on 10/06/10 at 1:20pm - 1:45pm SF2 LPC (Licensed Professional Counselor) intern and SF3 LCSW (Licensed Clinical Social Worker) indicated they are responsible for developing the goals for the Master Treatment Plan. Further they both indicated they are not familiar with the Psychiatric regulation requirements concerning short and long term goals.

In interview on 10/06/10 at 9:55 a.m. S1, Director of Nursing, confirmed that short-term and long-term goals should be written a way that would allow changes in a patient's behavior to be measured. Further, the DON indicated she was aware that additional work is needed on the treatment plans.

Based on record review and interview the hospital failed to ensure social services performed their assigned interventions specified in the patient's plan of care (Master Treatment Plan) for 4 of 4 patients reviewed for Treatment Planning in a total sample of 8 patients (#F4, #F5, #F6, #F7). Findings:

Patient #F4
Review of the medical record for Patient #F4 revealed she was admitted to the hospital on 09/24/10 with the diagnosis of schizoaffective disorder. Review of the Physician's Admit Orders dated 09/24/10 revealed under the section titled "Diagnostic Procedures" checked off was Group Therapy, Individual Therapy and Animal Assisted Therapy. Review of the Master Treatment Plan (approved by the patient #F4, Psychiatrist SF6, Licensed Clinical Social Worker (LCSW) SF3, RN SF7 and Dietitian SF8) revealed for Problem #1: Impulse Control and Labile Mood Social Services would teach patient cognitive methods for gaining control Monday through Friday.

Review of the "Daily Treatment Plan Update and Team Progress Notes" for Patient #F4 dated 09/24/10 through 10/05/10 revealed no documented evidence Social Services provided, via individual or group therapy, cognitive methods for gaining control on the following days: Wednesday, 09/29/10; Thursday, 09/30/10; Friday, 10/01/10; Monday, 10/04/10; or Tuesday, 10/05/10. Further review revealed no group therapy was provided on the weekends nor was any type of animal assisted therapy provided to Patient #F4 during the time period of 09/24/10 through 10/05/10 (date of the survey).

Patient #F5
Patient #F5 was admitted to the hospital on 10/01/10 with a diagnosis that included Bipolar Disorder, Suicide attempt, hyperlipidemia, insomnia, Degenerative joint disease lower back, osteoporosis. Review of Patient #F5's Physician's Admit Orders dated 10/01/10 at 12:40 a.m. revealed orders for Group Therapy, Individual Therapy, and Animal Assisted Therapy. Review of Patient #F5's Master Treatment Plan revealed that Social Services were to conduct group therapy, individual therapy, coping skills, and socialization 5 days a week Monday through Friday. Review of the medical record revealed no documented evidence the patient received group therapy, individual therapy, coping skills, or socialization from social services on the following dates: 10/01/10 (Saturday), 10/02/10 (Sunday), 10/03/10, and 10/04/10. Further review revealed that Patient #F5 participated in one group therapy session on 10/01/10 provided by SF5, Recreational Therapist. Review of Patient #F5's Master Treatment Plan revealed no documented evidence of a revision to the plan due to the patient's failure to participate in group or individual therapy sessions provided by social services. Review of the entire medical record revealed no documented evidence that Animal Therapy was provided as ordered.

Patient #F6
Review of the medical record for Patient #F6 revealed she had been admitted to the hospital for Schizoaffective Disorder on 09/23/10. Review of the Physician's Orders dated 09/23/10 #F6 was to have individual, group and animal assisted therapies. Review of the Master Treatment Plan dated 09/28/10 (approved by the patient #F6, Psychiatrist SF6, Licensed Clinical Social Worker (LCSW) SF3, RN SF9, SF5 Recreational Therapist and Dietitian, SF8) revealed Social Services was to conduct group to teach patient how to express angry feelings appropriately and the importance on medication compliance (5 times a week) and how the effects of blood pressure relate to mood and coping (daily).

Review of the "Daily Treatment Plan Update and Team Progress Notes" for Patient #F6 dated 09/23/10 through 10/05/10 revealed no documented evidence Social Services provided therapy to teach Patient #F6 how to express angry feelings 5 times a week or how the effects of blood pressure relate to mood and coping (daily) on the following days: Monday, 09/27/10; Wednesday, 09/29/10; Thursday, 09/30/10; Friday, 10/01/10; Monday, 10/04/10; or Tuesday 10/05/10. Further review revealed no group therapy was provided on the weekends nor was any type of animal assisted therapy provided to Patient #F4 during the time period of 09/24/10 through 10/05/10 (date of the survey).

Patient #F7
Patient #F7 was admitted to the hospital on 10/01/10 with a diagnosis that included vascular dementia secondary to cerebral vascular accident, depression, and psychosis. Review of Patient #F7's Physician's Admit Orders dated 10/01/10 at 8:15 p.m. revealed orders for group and individual Therapy. Review Patient #F7's Master Treatment Plan revealed that Social Services were to conduct group therapy on behavior management skills and relaxation techniques 4 times a week. Review of the medical record revealed no documented evidence the patient received group therapy or individual therapy from social services on the following dates: 10/01/10 (Saturday), 10/02/10 (Sunday), 10/03/10, 10/04/10, and 10/05/10. Further review revealed that Patient #F7 participated in one group therapy session on 10/04/10 provided by SF5, Recreational Therapist. Review of Patient #F7's Master Treatment Plan revealed no documented evidence of a revision to the plan due to the patient's failure to participate in group or individual therapy sessions provided by social services.

In interview on 10/06/10 at 11:05 a.m. SF1, Director of Nursing, indicated that the social worker should document group and individual meetings on the daily treatment plan update forms.

In interview on 10/06/10 at 1:30 p.m. SF3, Licensed Case Social Worker, indicated that group therapy sessions and individual therapy sessions should be documented when performed in the medical record. SF5 could provide no explanation as to why all group and individual therapy sessions were not documented in the medical record.

Based on record review and interview the hospital failed to ensure progress notes contained recommendations for revisions in the treatment plan as indicated for 4 of 4 patients reviewed whose charts had the revised Daily Treatment Plan Update and Team Progress Note out of a total sample of 8 patients (#F4, #F5, #F6, #F7). Findings:

Patient #F4
Review of the medical record for Patient #F4 revealed she had been admitted to the hospital for Schizoaffective Disorder on 09/24/10. Review of the Physician's Orders dated 09/24/10 #F6 was to have individual, group and animal therapies. Review of the Master Treatment Plan dated 09/28/10 and approved by the patient #F4, Psychiatrist SF6, Licensed Clinical Social Worker (LCSW) SF3, RN SF7 and Dietitian, SF8, revealed impulse control and labile mood; legal problems; discharge planning; and hypertension, diabetes and hyperlipidemia as Patient #F4's identified problems.

Review of the "Daily Treatment Plan Update and Team Progress Note" used by the hospital to document all individual and group therapy as well as progress made and recommended changes needed to the master treatment plan for the patient revealed the following:
Problem #1 (Impulse Control/Labile Mood)- Social Services was to teach patient cognitive methods for gaining control Monday through Friday; however there was no documented evidence methods for gaining control had been taught to the patient by social services or any other staff member.
Problem #2 (Legal Problems) -There was no documented evidence of the assessment of Patient #F4's behavior even though she was scheduled to appear in court on 10/01/10 concerning charges brought against her by her niece (Attacking the niece over money). Further review revealed no the nursing staff documented #F4 appeared anxious and talked about having to go to court; however there was no documented evidence therapy interventions had been implemented to address problem #2.
Problem #3 (Discharge Planning) Documentation revealed the patient would not be allowed to return to live with her niece; therefore other arrangements would have to be made. Review of the chart as of 10/06/10 (the day the patient was scheduled to be discharged) revealed no documented evidence living arrangements had been made for Patient #F4.
Problem #4 (Ineffective Management of Diabetes and Hyperlipidemia) revealed medical and pharmacological management by the physician; the skilled nurse would monitor and record the blood sugars, notify the physician if too low or too high; and educate the patient about diabetes. Review of the daily treatment plan revealed no documented evidence the blood sugars had been evaluated or recommendations made for the Master Treatment Plan.


Patient #F5
Patient #F5 was admitted to the hospital on 10/01/10 with a diagnosis that included Bipolar Disorder, Suicide attempt, hyperlipidemia, insomnia, Degenerative joint disease lower back, osteoporosis. Review of Patient #F5's Physician's Admit Orders dated 10/01/10 at 12:40 a.m. revealed orders for Group Therapy, Individual Therapy, and Animal Assisted Therapy. Review of Patient #F5's Master Treatment Plan revealed that Social Services were to conduct group therapy, individual therapy, coping skills, and socialization 5 days a week Monday through Friday. Review of the medical record revealed no documented evidence the patient received group therapy, individual therapy, coping skills, and socialization from social services on the following dates: 10/01/10 (Saturday), 10/02/10 (Sunday), 10/03/10, and 10/04/10. Further review revealed that Patient #F5 participated in one group therapy session on 10/01/10 provided by SF5, Recreational Therapist. Review of Patient #F5's Master Treatment Plan revealed no documented evidence of a revision to the plan due to the patient's failure to participate in group or individual therapy sessions provided by social services. Review of the entire medical record revealed no documented evidence that Animal Therapy was included as part of the patient's Master Treatment Plan or provided to the patient.

Patient #F6
Review of the medical record for Patient #F6 revealed she had been admitted to the hospital for Schizoaffective Disorder on 09/23/10. Review of the Physician's Orders dated 09/23/10 #F6 was to have individual, group and animal therapies. Review of the Master Treatment Plan dated 09/28/10 and approved by the patient #F6, Psychiatrist SF6, Licensed Clinical Social Worker (LCSW) SF3, RN SF9, SF5 Recreational Therapist and Dietitian, SF8, revealed anger, threatening behavior and ineffective management of HTN (Hypertension) and DM (Diabetes Mellitus) as Patient #F6's identified problems.

Review of the "Daily Treatment Plan Update and Team Progress Note" used by the hospital to document all individual and group therapy as well as progress made and recommended changes needed to the master treatment plan for the patient revealed the following:
Problem #1 (Anger and Threatening Behavior) Social services ws to conduct group to teach patient to express angry feelings appropriately; however there was no documented evidence social services had performed any group therapy involving anger management.
Problem #2 (Ineffective Management of HTN, DM) revealed the physician was responsible for stabilizing mood and behavior, the nurse was to monitor blood sugars and vital signs and report significant changes to the physician and social services was to instruct the patient on the importance of medication compliance and the effect mood has on blood pressure.

Review of the Treatment Plan Review dated 10/05/10 for Patient #F6 revealed the patient continued to be aggressive towards patients entering his room, intrusive to peers when they are talking, and patient is impulsive, labile and agitated. (after being in treatment at the hospital for 12 days). Further review revealed no documented evidence discussion had included the fact the treatment plan of group therapy by social services had not been implemented.

Patient #F7
Patient #F7 was admitted to the hospital on 10/01/10 with a diagnosis that included vascular dementia secondary to cerebral vascular accident, depression, and psychosis. Review of Patient #F7's Physician's Admit Orders dated 10/01/10 at 8:15 p.m. revealed orders for group and individual Therapy. Review Patient #F7's Master Treatment Plan revealed that Social Services were to conduct group therapy on behavior management skills and relaxation techniques 4 times a week. Review of the medical record revealed no documented evidence the patient received group therapy or individual therapy from social services on the following dates: 10/01/10 (Saturday), 10/02/10 (Sunday), 10/03/10, 10/04/10, and 10/05/10. Further review revealed that Patient #F7 participated in one group therapy session on 10/04/10 provided by SF5, Recreational Therapist. Review of Patient #F7's Master Treatment Plan revealed no documented evidence of a revision to the plan due to the patient's failure to participate in group or individual therapy sessions provided by social services.

In interview on 10/06/10 at 11:05 a.m. SF1, Director of Nursing, indicated that the physicians included the information in the treatment team meetings in their progress notes documented in the chart. After the DON reviewed the medical records of Patient #F4 and #F6, she verified the physician's progress note did not contain the information discussed in the Treatment Plan Review Meetings. SF1 then indicated the social worker should document group and individual meetings on the daily treatment plan update forms.

In interview on 10/06/10 at 1:30 p.m. SF3, Licensed Case Social Worker, indicated that group therapy sessions and individual therapy sessions should be documented when performed in the medical record. SF5 could provide no explanation as to why all group and individual therapy sessions were not documented in the medical record.

Based on record review and interview the hospital failed to ensure the Director of Social Services monitored the department for services provided as evidenced by failure to: 1) to ensure the patient's written plan of care (Master Treatment Plan) included short-term and long-term goals that were written in a way that would allow changes in the patient's behavior to be measured for 4 of 4 patients with the revised Master Treatment Plan which included short and long term goals reviewed for treatment planning out of a total sample of 8 patients (#F4, #F5, #F6, # F7); 2) ensure social services performed their assigned interventions specified in the patient's plan of care (Master Treatment Plan) for 4 of 4 patients reviewed for Treatment Planning in a total sample of 8 patients (#F4, #F5, #F6, #F7); and 3) ensure progress notes contained recommendations for revisions in the treatment plan as indicated for 4 of 4 patients reviewed whose charts had the revised Daily Treatment Plan Update and Team Progress Note out of a total sample of 8 patients (#F4, #F5, #F6, #F7). Findings:

1) ensure the patient's written plan of care (Master Treatment Plan) included short-term and long-term goals that were written in a way that would allow changes in the patient's behavior to be measured for 4 of 4 patients with the revised Master Treatment Plan which included short and long term goals reviewed for treatment planning (See findings at Tag B0121);

2) ensure social services performed their assigned interventions specified in the patient's plan of care (Master Treatment Plan) for 4 of 4 patients reviewed for Treatment Planning (See findings at Tag B0123);

3) ensure progress notes contained recommendations for revisions in the treatment plan (See findings at Tag B0131)