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Based on document review and interview, the facility failed to ensure all patient care personnel have CPR training, in 5 of 15 (#N1 (CNA), #N2 (CNA), #N4 (MHT), #N5 (MHT/Driver)and #N8 (MHT) nursing staff personnel files reviewed.

Findings Included:
1. Facility Policy titled Care and Maintenance of Personnel Records, HR 1.27, last updated 01/26/2017, indicated:
This information should include at a minimum;
(2) CPR/ First-Aid verification.
2. Nursing staff #N1 (CNA), #N2 (CNA), #N4 (MHT), #N5 (MHT/Driver)and #N8 (MHT) lacked documentation of current CPR or first aid training.
3. In interview on 4/29/2017 at 1615 hours, staff member #N9, Human Resources, indicated agreement that some of the personnel files lacked documentation of CPR or first aid status.

Based on document review and interview, the hospital's Quality Assurance Performance Improvement program (QAPI) did not include monitors and standards for 1 of 10 (dietetic service) directly-provided services and for 2 of 10 (animal therapy and transcription) contracted services, in calendar year 2016.

Findings included:

1. Review of the facility's QAPI program for calendar year 2016 indicated there were no monitors and standards for the directly provided dietetic service, and none for the contracted services of animal therapy and transcription.

2. In interview on 03-29-2017 at 1:55 pm, employee A2, Director Risk Management, confirmed all the above and no other documentation was provided prior to exit.

Based on document review and interview, the hospital's governing body did not ensure the facility's Quality Assurance Performance Improvement program (QAPI) involved 1 of 10 (dietary service) directly-provided services and 5 of 10 (animal therapy, biohazardous waste hauler, dietician, laundry and transcription) contracted services in calendar year 2016.

Findings included:

1. Review of the governing board minutes for calendar year 2016 indicated it could not be determined there was a review of the directly-provided dietary service, and the contracted services of animal therapy, biohazardous waste hauler, dietician, laundry and transcription.

2. In interview on 03-29-2017 at 1:55 pm, employee A2, Director Risk Management, confirmed all the above and no other documentation was provided prior to exit.

Based on documentation and interview, the facility failed to follow its policy for accurately maintain its controlled substance record in 1 facility.

Findings include:

1. Review of POLICY NUMBER - PHR -161, entitled PHARMACY CONTROLLED SUBSTANCE RECORD, Revised/Effective: 10/23/2013, indicated the pharmacy is to maintain a perpetual controlled substance inventory in the Pharmacy for Class II [C2] drugs.

2. On 03-28-2017 at 10:20 am, review of the pharmacy's CONTROLLED DRUG INVENTORY FORM indicated on the most recent date of 2/8/16, there should have been 30 pills of oxycontin 10 mg, a C2 drug, in the pharmacy's locked controlled substance storage cabinet.

3. On the above date and time, employee A7, pharmacist, was requested to count the current amount of the above-named medication in the controlled substances storage cabinet. In interview, the employee indicated there were 50 pills.

4. Review of the controlled substance log indicated there should have been 30 pills.

5. In interview on the above date and time, the employee was requested to provide an explanation for the discrepancy. The employee indicated it appeared there was a miscalculation of one of the entries in the past.

At this Life Safety Code survey, Options Behavioral Health System was found not in compliance with Requirements for Participation in Medicare, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This facility, located on the first and second floor of a two story building, was determined to be of Type II (222) construction and was fully sprinklered. The facility has a fire alarm system with smoke detectors in the corridor and in all areas open to the corridor. The facility has smoke detectors hard wired to the fire alarm system in all patient sleeping rooms. The facility has a capacity of 56 and had a census of 40 at the time of this survey.

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage areas was in accordance with NFPA 99 Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.3.1 states storage for nonflammable gases equal to or greater than 3000 cubic feet shall comply with 5.1.3.3.2 and 5.1.3.3.3. Section 5.1.3.3.2 states, if indoors, storage locations of positive-pressure gases shall be constructed and use interior finishes of noncombustible or limited combustible materials such that all walls, floor, ceilings, and doors are of minimum 1-hour fire resistant rating. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor ( see tag K923) and based on record review, observation and interview; the facility failed to ensure 1 of 1 oxygen storage locations where transfilling occurs was in accordance with NFPA 99, Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.5.2.3.1 states oxygen transfilling locations shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire resistive construction.
(2) The area is mechanically vented, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.
Section 11.5.3.2.3 states in health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no smoking language shall not be required. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor. (see tag K927).


The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 oxygen storage locations where transfilling occurs was in accordance with NFPA 99, Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.5.2.3.1 states oxygen transfilling locations shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire resistive construction.
(2) The area is mechanically vented, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.
Section 11.5.3.2.3 states in health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no smoking language shall not be required. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor.

Findings include:

Based on record review with the Director of Plant Operations and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, assessed patients are allowed to smoke in designated outdoor areas. Based on observations with the Chief Executive Officer (CEO), the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the following was noted at the oxygen storage and transfilling room on the first floor:
a. the corridor entry door was equipped with a self-closing device but had no affixed fire resistance rating label or fire resistant rating documentation available for review.
b. the room was not mechanically vented and did not have ceramic or concrete flooring.
c. the area was not posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
Two liquid oxygen containers were stored in the room as well as six 'E' type oxygen cylinders. In addition, observation with Maintenance Technicians I and II at 10:45 a.m. on 03/28/17 noted a six inch in diameter hole in the corridor wall above the suspended ceiling above the corridor entry door to the room which also did not enclose the room with 1 hour fire resistive construction. Based on interview at the time of the observations, the CEO, DPO and Maintenance Technicians I and II acknowledged the aforementioned observations.

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage areas was in accordance with NFPA 99 Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.3.1 states storage for nonflammable gases equal to or greater than 3000 cubic feet shall comply with 5.1.3.3.2 and 5.1.3.3.3. Section 5.1.3.3.2 states, if indoors, storage locations of positive-pressure gases shall be constructed and use interior finishes of noncombustible or limited combustible materials such that all walls, floor, ceilings, and doors are of minimum 1-hour fire resistant rating. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the following was noted at the oxygen storage and transfilling room on the first floor:
a. the corridor entry door was equipped with a self-closing device but had no affixed fire resistance rating label or fire resistant rating documentation available for review.
b. the room was not mechanically vented and did not have ceramic or concrete flooring.
Two liquid oxygen containers were stored in the room as well as six 'E' type oxygen cylinders. In addition, observation with Maintenance Technicians I and II at 10:45 a.m. on 03/28/17 noted a six inch in diameter hole in the corridor wall above the suspended ceiling above the corridor entry door to the room which also did not enclose the room with 1 hour fire resistive construction. Based on interview at the time of the observations, the CEO, DPO and Maintenance Technicians I and II acknowledged the aforementioned observations.

Based on observation, the hospital created 1 condition which resulted in a hazard to employees.

Findings include:

1. On 03-28-2017 at 10:30 am in the presence of employees A1, Administrator and A6, Maintenance, it was observed in the pharmacy room there was an alcohol-based hand sanitizer (ABHS) on the wall directly above an electronic telephone.

2. In the above situation. the location of the ABHS alcohol-based hand sanitizers, directly above an ignition source, posed a fire hazard if the flammable alcohol was sprayed or dropped into the electrical ignition source.

33212

Based on observation, document review and interview, the facility failed to identify and remove expired nutrition supplements for 1 general storage area, and failed to ensure that the infection control officer developed a system to identify the immunization status of it's nursing personnel, in 15 of 15 personnel files reviewed. (staff N#1, N#2, N#3, N#4, N#5, N#6, N#7, N#8, N#9, N#10, N#11, N#12, N#13, N#14, and N#15)

Findings included:

1. On 3-28-2017 at 10:05 am in the presence of employees A1, Administrator and A6, Maintenance, it was observed on an in-use shelf in the general storage room, that there were six 8-ounce cans of Special Nutrition Supplement each having an expiration date of 1 March 2017.

2. Review of a document entitled Facility Policy titled Care and Maintenance of Personnel Records, HR 1.27, last updated 01/26/2017, indicated:
(16) Documentation of all mandatory health and immunization procedures.

3. Staff fill out a common infectious disease checklist (Rubella, Rubeola and Varicella) at their pre-employment health assessment. Staff N#1, N#3, N#4, N#5, N#6, N#7, N#8, N#10, N#11, N#12, N#13, N#14, and N#15, did not fill in the checklist.

4. Review of the personnel files for staff N#1, N#2, N#3, N#4, N#5, N#6, N#7, N#8, N#9, N#10, N#11, N#12, N#13, N#14, and N#15 lacked documentation of proof of immunization status with disease antibody titers or other means.

5. In interview on 4/29/2017 at 1600 hours, staff member #N9, Human Resources, indicated agreement that the personnel files lacked immunization status.

Based on document review and interview, the facility failed to follow procedures, as contracted with an organ procurement organization, upon the death of a patient, for 1 facility.

1. Review of a document entitled HOSPITAL PROCUREMENT AGREEMENT (ORGAN, TISSUE AND EYE - Behavioral Health), dated March 10, 2015, between Options Behavioral Health System ("Hospital") and Indiana Organ Procurement Organization, Inc., d/b/a/ Indiana Donor Network ("Indiana Donor Network"), indicated the hospital would provide "... Timely Referral to Indiana Network of Imminent Deaths and deaths which occur in Hospital ...".

2. In interview on 03-30-2017 at 1:15 pm, employee A1, Administrator, confirmed the above-stated contract, employee A1, Director Risk Management, indicated there was a hospital death on January 31, 2017, and employee A5, Director of Nursing indicated the hospital did not report the death to the Indiana Donor Network.

Based on record review and staff interview, it was determined that for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, C2, D1, D2, and D3) there was a failure to include in the Psychosocial Assessment a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being made available to other members of the treatment team about what anticipated efforts might be made to facilitate discharge planning.

Findings include:

A. Record Review

1. Patient A1: The Psychosocial Assessment, dated 3/19/17, stated as the anticipated role of the social service staff, "[Name of staff] will provide DBT (Dialectical Behavior Therapy) with patient A1 to help process through [his/her] emotions." No comment was present about what efforts were anticipated toward discharge.

2. Patient A2: The Psychosocial Assessment, dated 2/15/17, stated: "It is the role of the therapist to ensure clinical needs are met, including group process therapy, activity therapy, family therapy, individual therapy as needed and medication management." While these types of therapy may benefit the patient, this was not a description of what efforts toward discharge planning will be made by social service and medication management is a responsibility of the psychiatric staff.

3. Patient B1: The Psychosocial Assessment, dated 3/27/17, had no anticipated role for social service staff described.

4. Patient C1: The Psychosocial Assessment, dated 3/23/17, stated: "Therapist will provide BPSA (Biopsychosocial Assessment), group therapy, cognitive behavioral therapy and ensure medication management."

5, Patient C2: The Psychosocial Assessment, dated 3/20/17, stated: "Therapist will provide BPSA, group therapy, cognitive behavioral therapy and ensure medication management."

6. Patient D1: The Psychosocial Assessment, dated 3/22/17, stated: "Therapist [name of therapist) will work with Patient D1 on processing & identifying triggers."

7. Patient D2: The Psychosocial Assessment, dated 3/24/17, stated: "Pt. [patient] should follow up with outpatient therapy and commit to being drug free." These goals did not disclose what the anticipated role of the social service staff would be to affect these outcomes.

8. Patient D3: The Psychosocial Assessment, dated 3/26/17, stated: "Therapist [name of therapist] will provide therapy to help Patient D3 process through feelings and emotions."

B. Staff Interview

On 3/28/17 at 9:00 a.m., the Director of Social Services was interviewed. The Director looked at several of the examples cited in Section A, above. The Director agreed that, as described, the role of social service staff toward discharge planning was not described.

The Director was also asked to explain how the Multidisciplinary Treatment Plan for Patient A1, dated 3/16/17, could be generated when the Psychosocial Assessment had not been done until 3/19/17. For Patient A2, the Multidisciplinary Treatment Plan dated 2/14/17, had a Psychosocial Assessment, dated 2/15/17. The Director explained that the social service staff's work load had probably necessitated that happening. Per the Director, both the Treatment Plan and the Psychosocial Assessment were to be completed within 72 hours of admission.

Based on record review and staff interview, it was determined that for seven (7) of eight (8) active sample patients (A1, B1, C1, C2, D1, D2, and D3), the Psychiatric Evaluations failed to include an assessment of the patient's assets in descriptive, not interpretive fashion. This failure results in no information for the other members of the multidisciplinary treatment team, such as patient accomplishments, goals, interests, etc., that might aid in the selection of treatment modalities.

Findings include:

A. Record Review
1. Patient A1: The Psychiatric Evaluation, dated 3/15/17, stated as the patient's assets "generally healthy, supportive bio-parents, attends public education without cognitive limitations."

2. Patient B1: The Psychiatric Evaluation, dated 3/24/17, stated: "Supportive family" and "Good verbal skills" as the patient's assets.

3. Patient C1: The Psychiatric Evaluation, dated 3/21/17, stated: "Generally healthy, independent with ADL's (activities of daily living) supportive family" as the patient's assets.

4. Patient C2: The Psychiatric Evaluation, dated 3/18/17, stated: "Good physical health" and "Motivation to receive treatment" as the patient's assets.

5. Patient D1: The Psychiatric Evaluation, dated 3/23/17, stated: "Good verbal skills and good work skills" as the patient's assets.

6. Patient D2: The Psychiatric Evaluation, dated 3/23/17, stated: "Good health and good verbal skills" as the patient's assets.

7. Patient D3: The Psychiatric Evaluation, dated 3/25/17, stated: "Intelligent/kind" as the sole description of assets.

B. Staff Interview

On 3/28/17 at 3:35 p.m., the facility's Clinical Director was interviewed. The findings described in Section A above were a partial focus of the interview. The Clinical Director agreed that these statements were not assessments of inherent patient assets.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patient's psychiatric condition for five (5) of eight (8) active sample patients (B1, C1, C2, D1, and D3). Many of the goals were either not measurable or were staff goals (what staff want the patient to achieve), rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Facility policy, No. PC8.07, titled: "Master Treatment Planning (MTP) (acute)," last reviewed 1/23/17, stated: "The MTP shall contain a specific long-term goal, the patient's goal in their own words, short-term goal(s)," --- "The goals should all be described in measurable terms." Many of the goals were not stated in measurable terms.

2. In patient B1's MTP, dated 3/27/17, there was no long-term goal. The unmeasurable short-term goals were: "[Name of patient] will orient [him/herself] to person, setting and circumstances for 3 consecutive days." "Will be able to verbally explain the benefits of cooperating with [his/her] medications for 3 consecutive days."

3. In patient C1's MTP, dated 3/23/17, the non-measurable long-term goal was, "[Name of patient] will use [his/her] coping skills to maintain positive rational thoughts and words and actions." What specific actions must the patient display to know s/he has accomplished this? The short-term staff goals were: "[Name of patient] will participate in group therapy, learning coping skills of deep breathing, visualization and meditation for 3 days." "[Name of patient] will participate in taking [his/her] Trileptal and Trazadone to assist in reduction of depression and mania 3 days." These were goals staff wanted the patient to achieve.

4. In patient C2's MTP, dated 3/20/17, a non-measurable short-term goal was, "[Name of patient] will learn coping skills of coloring, going for a walk, deep breathing to reduce depression and anxiety for 3 days." A short-term staff goal was, "[Name of patient] will participate in taking Seroquel, Trazodone, Trileptal and Gabapentin to assist in removal of depression and psychosis 3 days [sic]."

5. In patient D1's Master Treatment Plan (MTP), dated 3/22/17, the unmeasurable long-term goal was, "[Name of patient] will learn how to identify and utilize coping skills to deal with what triggers [his/her] emotions." The unmeasurable short-term goals were: "[Name of patient] will go 2 -3 days without having suicidal thoughts or ideations, will learn to verbalize [his/her] feeling suicidal." "[Name of patient] will learn 3 - 4 effective coping skills to utilize with expressing feelings and emotions." What statements or behaviors can one use to determine if the patient has achieved these goals?

6. In patient D3's MTP, dated 3/24/17, a non-measurable long-term goal was, "[Name of patient] will be free from having current suicidal thoughts." How can one tell this without citing specific behaviors or verbal expressions about this topic? A short-term staff goal was, "[Name of patient] will start medications that will help to decrease suicidal thoughts."

B. Interview

In an interview on 3/27/17 at 9:30 a.m., the non-measurable and/or staff long and short-term goals were discussed with RN1. She did not dispute the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, C2, D1, D2, and D3) that included individualized physician and nursing interventions based on each patient's specific problems. Both physician and nursing interventions were generic discipline functions/tasks that one would do for any and all patients. Both physician and nursing interventions were identical or similarly worded for all eight (8) patients. Failure to clearly define specific modalities on patient's MTPs can hamper staff's ability to provide treatment based on each patient's needs.

Findings include:

A. Record Review

1. Facility policy, No. P 8.07, titled: "Master Treatment Planning (MTP) (acute)," last reviewed 1/23/17, stated: "Options shall detail specific interventions to be delivered." There was no other description of what should be included in the intervention that related to each patient's specific problem.

2. Patient A1, (MTP dated 3/16/17), had the following interventions for the problem of, "Depressed mood with psychosis as manifested by/as evidenced by: Feelings of isolation, hopelessness, feeling alone & (and) thoughts of suicide." The physician intervention was, "Prescribe meds R/T dx [related to diagnosis], monitor effectiveness, and make changes as needed." The nursing intervention was, "Prescribe meds as ordered, monitor for/report SIE [suicidal ideations]."

3. Patient A2, (MTP dated 2/4/17), had the following interventions for the problem of, "Depressed mood with psychosis as manifested by/as evidenced by: Patient reported having a plan of suicide. Patient reports no one likes [her/him] and that [s/he] had previous suicide attempt when [s/he] lived in Africa." The physician intervention was, "Begin psychotropic med regimen, and [illegible phrase]." The nursing intervention was, "Administer medications as prescribed by physician."

4. Patient B1, (MTP dated 3/27/17), had the following interventions for the problem of, "Disturbed thought as manifested by/as evidenced by: A report from North Capital Nursing and Rehab [Rehabilitation] indicated that Trump & Muslims are a concern as well as beliefs that residents are in collusion with staff to do [him/her] [sic]. [S/he] is refusing medications." The physician intervention was, "Prescribe meds R/T dx, minimize effectiveness & make changes as needed." The nursing intervention was, "Administer meds as ordered, monitor for reports/E [effectiveness]."

5. Patient C1, (MTP dated 3/23/17), had the following interventions for the problem of, "Manic mood with psychosis as manifested by/as evidenced by: [Name of patient] arrived with acute psychosis, reported [s/he] works for Trump, [s/he] needs to keep confidential, reported [s/he] hears voices and want to kill [himself/herself], stated [s/he] would kill [himself/herself] by wrecking [his/her] car or hanging [himself/herself] and significant other said [s/he] stopped [his/her] medications and has been screaming at [himself/herself]." The physician intervention was, "Prescribe medication & monitor for side effects." The nursing intervention was, "Administer medication & monitor for side effects."

6. Patient C2, (MTP dated 3/20/17), had the following interventions for the problem of, "Depressed mood with psychosis as manifested by/as evidenced by: Ideations plans and attempts, tried to hang [himself/herself] to end [his/her] life, currently homeless, unemployed, very limited family support, reported a friend brought [him/her] to hospital for treatment, reported has history of psychosis, recently released from [name of hospital], but could not afford prescriptions once discharged." The physician intervention was, "Prescribe medication based upon diagnosis and adjust as needed." The nursing intervention was, "Follow MD orders for medication management and watch for S/S [signs and symptoms] adverse effects of medications."

7. Patient D1, (MTP dated 3/22/17), had the following intervention for the problem of, "Depressed mood without psychosis as manifested by/as evidenced by: Suicidal ideations, mood changes, isolations & irritability." The physician intervention was, "Prescribe medication based on diagnosis and adjust as needed." The nursing intervention was, "Follow MD orders for medication management and adjust as needed."

8. Patient D2, (MTP dated 3/24/17), had the following interventions for the problem of, "Depressed mood without psychosis as manifested by/as evidenced by: Pt attempted to kill [himself/herself] because [his/her] [boyfriend/girlfriend] was trying to break up [with] [him/her]. [S/he] had 4 - 5 attempts due to relationship issues." The physician intervention was, "Prescribe medication based upon diagnosis and adjust as needed." The nursing intervention was, "Follow MD orders for medication management and watch for S/S of adverse effects of medication."

9. Patient D3, (MP dated 3/24/17), had the following interventions for the problem of, "Depressed mood without psychosis as manifested by/as evidenced by: Suicidal thoughts, ideations, feelings of hopelessness & frustration." The physician intervention was, "Monitor and adjust [name of patient's] meds as necessary, assess mental status and med effectiveness." The nursing intervention was, "Administer [name of patient's] meds and monitor for side effects, assess mental and behavioral status, dx [diagnose] perception of improvement and mood effectiveness [sic]."

B. Interviews

1. In an interview on 3/28/17 at 9:00 a.m., the director of Clinical Services (Social Worker) was interviewed. She was shown the treatment plans for active sample patients C1 and C2. The director agreed that the interventions were generic discipline functions.

2. In an interview on 3/28/17 around 11:00 a.m., the generic nursing interventions on the MTPs were discussed with the Nursing Director. She did not dispute the findings.

Based on record review and interview, the Medical Director failed to monitor the quality of the interventions on the Master Treatment Plans. Specifically, the Medical Director failed to ensure that for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, C2, D1, D2, and D3) physician and nursing interventions were based on each patient's specific problems. Both physician and nursing interventions were generic discipline functions/tasks that one would do for any and all patients. Both physician and nursing interventions were identical or similarly worded for all eight (8) patients. Failure to clearly define specific modalities on patient's MTPs can hamper staff's ability to provide treatment based on each patient's needs. (Refer to B122.)

Based on record review and interview, the Director of Nursing failed to monitor the quality of the discipline intervention on the Master Treatment Plan. Specifically, the Director of Nursing failed to ensure that for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, C2, D1, D2, and D3) the nursing interventions were based on each patient's specific problems. The nursing interventions were generic discipline functions/tasks that one would do for any and all patients. Nursing interventions were identical or similarly worded for all eight (8) patients. Failure to clearly define specific modalities on patient's MTPs can hamper staff's ability to provide treatment based on individual patient needs. (Refer to B122.)

Based on record review and staff interview, it was determined that the Director of Social Services failed to ensure that for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, C2, D1, D2, and D3) the Psychosocial Assessments contained a description of the anticipated efforts of the social service staff toward discharge planning. (Refer to B108.)