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Based on record review, interview, observation, and document review the facility failed to:

I. Provide active treatment including alternative interventions for three (3) of three (3) active sample patients (G5, G6, and G7) on the Secure Unit. All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement. (See B125-l)

II. Provide individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement and discharge. (See B125-ll)

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified patient-centered short-term goals stated in behavioral terms for eight (8) of eight (8) active patients (G1, G2, G3, G4, G5 G6, G7, and G8). Lack of measurable, patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

A. Record Review

1. Patient G1 was admitted on 11/10/14. The Master Treatment Plan dated 11/10/14 identified the problem, "Risk for Suicide." The goals listed were "Pt [patient] will be stabilized of [his/her] mental illness" and "Pt will contract for safety during hospitalization process."

2. Patient G2 was admitted on 11/08/14. The Master Treatment Plan dated 11/09/14 identified the problem "Risk for Suicide." The short-term goal listed was "Patient will demonstrate increased insight regarding suicidal ideations, intentions, and attempts as evidenced by verbally recognizing three (3) times, prior to discharge, that when the level of control over their own behavior/actions decreases it increases patient's risk for harm to self or others."

3. Patient G3 was admitted on 11/12/14. The Master Treatment Plan dated 11/12/14 identified the problem "Continuity of Care." The short-term goal for this problem was "Patient will make a determination regarding post discharge placement to a safe and appropriate setting." [This patient had arrived illegally into the United States, was under the control of the INS, and, therefore has no say in his/her discharge plan which will be determined by the INS.]

4. Patient G4 [a 13 year old] was admitted 11/13/14. The Master Treatment Plan dated 11/13/14 identified the problem "Continuity of Care." The short-term goal was "Patient will make a determination regarding post discharge placement to a safe and appropriate setting."

5. Patient G5 was admitted on 11/9/14. The Master Treatment Plan dated 11/9/14 identified the problem, "Risk for Suicide." The short-term goal for this problem was "Patient will demonstrate increased insight regarding suicidal ideations, intentions, and attempts as evidenced by verbally recognizing four (4) times, prior to discharge, that when the level of control over their own behavior/actions decreases it increases patient's risk for harm to self or others."

6. Patient G6 was admitted on 9/23/14. The Master Treatment Plan dated 9/23/14 identified the problem, " Hallucinations." The short-term goal for this problem was, "Patient will demonstrate a decrease in hallucinations as evidenced by verbalizing a decrease in frequency and intensity of hallucinations from one (1) to zero (0) a day."

7. Patient G7 was admitted on 11/5/14. The Master Treatment Plan dated 11/5/14 identified the problem, "Paranoid and/or Delusional Thoughts/Behaviors." The short-term goal for this problem was, "Patient will demonstrate increased insight regarding their illness as evidenced by discussing the content of their delusions with staff three (3) times per day for seven (7) days."

8. Patient G8 was admitted on 11/12/14. The Master Treatment Plan dated 11/12/14 identified the problem, "Paranoid and/or Delusional Thoughts/Behaviors." The short-term goal for this problem was, "Patient will demonstrate increased insight regarding their illness as evidenced by discussing the content of their delusions with staff three (3) times per day for seven (7) days."

B. Interview

1. In interview on 11/18/14 at 3:30 p.m., the Chief Nursing Officer agreed that the short-term goals for the sample patients were not measurable.

Based on record review and interview, the facility failed to identify in the MTP specific treatment modalities to address the identified patient problems for seven (7) of eight (8) active patients (G1, G2, G3, G5, G6, G7 and G8). The treatment interventions were stated in vague terms and were generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention designed to achieve measurable behavioral outcomes for patients.

Findings include:

A. Specific Patients

1. Patient G1 was admitted on 11/10/14. The Master Treatment Plan dated 11/10/14 identified the problem, "Risk for Suicide." The interventions to address this problem included the nursing interventions, "Staff will prevent anxiety/agitation from increasing within the environment by monitoring patient response to others and surrounding during unit supervision for three (3) days" and the social worker/case manager (CM) intervention, "CM will prompt patient to recognize the physiological and emotional signs demonstrated in response to triggers in which suicidal ideations can be averted through and awareness exercises in Psychotherapy Groups for 10 mins[minutes]."

2. Patient G2 was admitted on 11/08/14. The Master Treatment Plan dated 11/09/14 identified the problem "Risk for Suicide." The interventions to address the problem included the nursing intervention, "Staff will provide reassurance and support during interactions to maintain a calm and safe environment for the patient for three (3) days "and the social worker/case manager intervention" CM will prompt patient to recognize the physiological and emotional signs demonstrated in response to triggers in which suicidal ideations can be averted through awareness exercises in Psychotherapy Groups for 10 mins [minutes]."

3. Patient G3 was admitted on 11/12/14. The Master Treatment Plan dated 11/12/14 identified the problem "Continuity of Care." The interventions to address this problem included the nursing intervention, "Nurse will provide patient and parent/guardian (if applicable) instructions regarding medication administrations and teaching" and the social worker/case manage intervention "CM will verify placement appropriateness and acceptability within two (2) days from admission."

4. Patient G5 was admitted on 11/9/14. The Master Treatment Plan dated 11/9/14 documented the problem, "Suicidal Thoughts/Plans." The interventions to address this problem included the nursing intervention "Staff will assess mood and depressive symptoms every shift", the social worker/case manager (CM) intervention, "CM will provide one (1) on one (1) intervention with patient for at least (left blank) minutes utilizing Person Centered Approach or Cognitive Behavioral Therapy" and the recreation therapy (RT) intervention, "RT staff will through leisure education and counseling, support patient options for avoiding hopelessness and helpless thoughts."

5. Patient G6 was admitted on 9/23/14. The Master Treatment Plan dated 9/23/14 documented the problem, "Hallucinations." The interventions to address this problem included the nursing intervention, "Staff will assess for severity of impairment in daily functioning every shift" and the RT intervention, "RT staff will provide structured activity per unit schedule to promote routine."

6. Patient G7 was admitted on 11/5/14. The Master Treatment Plan dated 11/5/14 documented the problem, "Paranoid and/or Delusional Thoughts/Behaviors." The interventions to address this problem included the nursing intervention, "Staff will assess for signs and symptoms of paranoid or delusional thinking" and the RT intervention, "RT staff will provide structured activity per unit schedule to promote routine."

7. Patient G8 was admitted on 9/23/14. The Master Treatment Plan dated 9/23/14 listed the problem, "Hallucinations." The interventions to address this problem included the nursing intervention, "Staff will assess for severity of impairment in daily functioning every shift" and the RT intervention, "RT staff will through leisure education and counseling support patients options for avoiding hypervigilance and obsessive thoughts."

B. Interview

In interview on 11/18/14 at 3:30 p.m., the Chief Nursing Officer acknowledged that the interventions documented on the Master Treatment Plans of sample patients were vague and were not individualized.

Based on record review, interview, observation, and document review the facility failed to provide:

l. Active treatment including alternative interventions for three (3) of three (3) active sample patients (G5, G6, and G7) on the Secure Unit. All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

ll. Individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion potentially delaying improvement and discharge. Findings include:

l. Treatment Interventions

A. Patient Findings

1. Patient G5 was admitted on 11/9/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G5 failed to attend 63% of his/her assigned groups. Review of the Special Observation Record which recorded patient location every 15 minutes, revealed that Patient G5 was listed as "In Group" (location key eight "8") only on two (2) occasions from 11/10/14-11/17/14 (11/17/14 at 1:30 p.m. and 1:45 p.m.). Review of the Master Treatment Plan revealed that Patient G5's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 2:30 p.m., Patient G5 stated that he/she did not go to groups because "I'm sleepy and depressed. They let me stay in bed most of the day except for smoke breaks."

In interview on 11/18/14 at 9:45 a.m., CBHT1 stated, "[Patient] doesn't attend many groups. S/he usually stays in bed."

In interview on 11/18/14 at 9:55 a.m., RN1 stated that Patient G5 "stays in [his/her] room."

During observation on the Secure Unit, Patient G5 was observed in bed, under the covers on 11/17/14 at 2:00 p.m. (Recreation Therapy Group in progress). Patient G5 was also observed in bed on 11/18/14 at 9:45 a.m. (Current Events Group in progress) and on 11/18/14 at 10:15 a.m. (Recreational Therapy Group in progress).

2. Patient G6 was admitted on 9/23/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G6 failed to attend 41% of his/her assigned groups. Review of the Special Observation Record revealed that Patient G6 was listed as "In Group" (location key eight "8") only on two (2) occasions from 11/10/14-11/17/14 (11/15/14 at 9:15 a.m. and 9:30 a.m.). Review of the Master Treatment Plan revealed that Patient G6's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 3:00 p.m., Patient G6 stated that he/she spent the day "smoking cigarettes, reading the Bible and watching tv." S/he further stated that the groups were not interesting and "they do the same things over and over."

In interview on 11/18/14 at 9:55 a.m., RN1 stated that Patient G6 was waiting to go to the State Hospital where s/he could get substance abuse treatment. RN1 further stated that Patient G6 did not go to groups very often.

During observations on the Secure Unit, Patient G6 was observed in bed, under the covers on 11/17/14 at 2:30 p.m. (Recreation Group in progress). Patient G6 was also observed in bed on 11/18/14 at 9:40 a.m. (Current Events Group in progress), at 10:15 a.m. (Recreation Group in progress) and at 2:30 p.m. (Recreation Group in progress).

3. Patient G7 was admitted on 11/5/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G7 failed to attend 46.8 % of his/her assigned groups. Review of the Master Treatment Plan revealed that Patient G7's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 2:45 p.m., Patient G7 stated that s/he did not like the groups and didn't go to them. Patient G7 further stated that S/he spent a lot of time in bed.

In interview on 11/18/14 at 10:00 a.m., RN2 stated that Patient G7 was "disorganized." Patient G7 was on one (1) on one (1) observation and RN2 stated that the one (1) on one (1) staff sometimes took the patient to groups.

During observation on the Secure Unit, Patient G7 was observed in bed, under the covers on 11/17/14 at 11:15 a.m. (Goals Group in progress) and 2:45 p.m. (Recreation Group in progress).

ll. Individualized Active Treatment

A. Document Review

1. The group activity schedule for the Secure Unit revealed that no therapeutic activities were scheduled daily from 3:00 p.m.-8:00 p.m. The 8:00 p.m. activity was a 30 minute Goal Accomplishment group led by a Certified Behavioral Health Tech (CBHT). The week-end schedule documented two CBHT led Goals Group per day, one CBHT led Current Events group per day, one Movie Time per day and one Recreation Therapy (RT) group per day (one RT group was a Social Hour group where food was served).

2. The group activity schedule for the Adult Open/Senior Unit revealed that no therapeutic activities were scheduled daily from 2:30 p.m.-8:00 p.m. The 8:00 p.m. activity was a 45 minute Goal Accomplishment group led by a CBHT. The week-end schedule documented one CBHT led Goals Group per day, one Movie Time per day, one nursing led Nutrition Education and one Medication Education group. One Social Hour group and one CBHT led Current Events group per day.

3. The group activity schedule for the Adolescent Unit evenings and weekends revealed that there were no scheduled evening treatment groups for the adolescents after 5:00 p.m., except an 8:00 p.m. half (½) hour long Goals Accomplishment Group conducted by a (CBHT) Certified Behavioral Health Tech. On weekends there was only a Goals Group/Feelings Process on Saturday and Sunday and a Recreation Therapy Group for half (½) an hour on Saturday only.

B. Interviews

1. In interview on 11/18/14 at 9:40 a.m., CBHT1 on the Secure Unit stated that on the week-ends Recreational Therapy groups usually involved food and eating. CBHT1 acknowledged that there were no therapeutic groups offered on the Secure Unit from 3:00 p.m.-8:00 p.m.

2. In an interview on 11/18/14 at 9:50 a.m., RN1 upon review of the Adolescent Evening and Weekend schedule, concurred there were no scheduled evening treatment groups for the adolescents after 5:00 p.m., except an 8:00 PM half hour long Goals Accomplishment Group conducted by a (CBHT) Certified Behavioral Health Tech. On weekends s/he concurred that there was only a Goals Group/Feelings Process on Saturday and Sunday and a Recreation Therapy Group for half (½) an hour on Saturday only. RN1 did indicate that evenings and weekends were utilized for family therapy sessions.

3. In an interview on 11/17/14 at 3:00 p.m. Adolescent Patient G2 indicated that the weekends were boring. S/he further noted that there were few therapeutic activities on the weekends. With further questioning about evening programming, she indicated "Nothing goes on."

Based on interview, observation, document review, the medical director failed to:

I. Ensure that active treatment, including alternative interventions, were provided for three (3) of three (3) active sample patients (G5, G6, and G7) on the Secure Unit. All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement (See B125-l).

II. Ensure the provision of individualized active treatment for eight (8) of eight (8) sample patients (G1, G2, G3, G4, G5, G6, G7, and G8) on evenings and weekends. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided in a timely fashion and potentially delaying improvement and discharge (See B125-ll).

III. Ensure that a physician directed treatment teams met in a formal meeting to design a Multidisciplinary Treatment Plan. Instead treatment team members wrote separately on the treatment plan at different times and simply signed a document.

A. Interviews

1. In an interview on 11/17/14 at 2:30 p.m., the medical director concurred there were no formal treatment team meetings. She indicated each discipline completed the form separately after discussing the case with each other.

2. In an interview on 11/17/14 at 2:30 p.m., Patient G5 stated that a staff member had brought him/her a treatment plan to sign. Patient G5 further stated that since s/he could not see the treatment plan (left glasses at home) s/he did not know what it said. When asked if the staff member had read the treatment plan aloud, Patient G5 stated "no I just signed it."

3. In an interview on 11/17/14 at 3:00 p.m., Patient G2 stated s/he had not attended a treatment team meeting regarding his/her treatment plan and had not seen a treatment plan.

4. In an interview on 11/17/14 at 3:20 p.m., Patient G1 stated h/she had not attended a treatment team meeting regarding his/her treatment plan and had not see a treatment plan.

5. In an interview on 11/18/14 at 9:50 a.m., RN1 indicated there was not a formal treatment team meeting where patient treatment plans including problems, goals, and interventions were formulated. Treatment team members separately listed their interventions on the treatment plan document and team members independently signed the treatment plan.

6. In an interview on 11/18/14 at 2:15 p.m. Physician I was interviewed regarding his/her role in coordinating treatment planning weekly on the Adolescent Unit. S/he noted that his/her role was to assure coordination of care and not interfere with other physician treatment of patients. If h/she though changes were indicated a phone call would be made to the appropriate physician.

7. In an interview on 11/18/14 at 10:10 a.m. SW3 discussed his/her participation in the treatment plan process. S/he indicated that problems, goals, and intervention formulation began on admission. When questioned if his/her goals could be established prior to completion of the social services assessment s/he said no, but that s/he had been told to sign the treatment plan document on the day following admission along with other members of the team. S/he further indicated there was not a formal meeting of the teatment team to discuss the treatment plan.

IV. Ensure the Legibility Physician Documentation in the Medical Record

A. Record Review

1. Upon review of Patient G4's medical record on 11/18/14 at 10:00 a.m., the physician surveyor could not read the physician orders dated 11/17/14 and physician progress notes entered 11/4/14 at 1:15, 11/15/14 at 2:00 p.m., and 11/16/14 at 4:00 p.m.

B. Interviews

1. The physician surveyor requested on 11/18/14 at 10:00 a.m. RN3's assistance in reading the chart. S/he indicated he/she knew what the orders meant and what the doctor intended, but could not read the documentation. S/he further noted that he/she could not read the progress notes. S/he further checked the computer to see if the notes had been dictated and noted that they had not.

2. In an interview on 11/18/14 at 10:10 a.m., SW3 indicated that s/he as well could read neither the doctor's orders nor the progress notes.

V. Document and Notify Patient Family of Abnormal Laboratory Results

A. Record Review

1. On review of Patient G4's medical record on 11/18/14 at 10:00 a.m., the physician surveyor noted an abnormal TSH value for the patient and could not find documentation that the patient's family had been notified and appropriate follow-up appointments had been arranged.

B. Interviews

1. In an interview with RN3 on 11/18/14 at 10:00 a.m. s/he indicated s/he thought the discharge social worker probably informed the family.

2. In an interview on 11/18/14 at 10:10 a.m. SW3 noted that s/he thought the discharging RN had informed the family.

3. In an interview on 11/18/14 at 3:00 p.m. the Director of Nursing informed the surveyors that the discharging physician was contacted, the family was informed of the abnormal laboratory values, and an appointment had been made with the outpatient physician for further follow up of the abnormal thyroid findings.

Based on record review and interview, the Director of Nursing failed to ensure that the nursing staff:

l. Identify in the MTP specific nursing treatment modalities to address the identified patient problems for seven (7) of eight (8) active patients (G1, G2, G3, G5, G6, G7, and G8). The treatment interventions were stated in vague terms and were generic discipline functions rather than directed at specific interventions. This deficiency results in failure to guide nursing staff regarding the specific treatment purpose of each intervention designed to achieve measurable behavioral outcomes for patients.

ll. Provide active treatment including alternative interventions for three (3) of three (3) active sample patients (G5, G6, and G7) on the Secure Unit. All of the patients were unwilling to attend many of their assigned groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement.

Findings include:

l. Nursing Treatment Modalities

A. Specific Patients

1. Patient G1 was admitted on 11/10/14. The Master Treatment Plan dated 11/10/14 identified the problem, "Risk for Suicide." The interventions to address this problem included the nursing interventions "Staff will prevent anxiety/agitation from increasing within the environment by monitoring patient response to others and surrounding during unit supervision for three (3) days."

2 Patient G2 was admitted on 11/08/14. The Master Treatment Plan dated 11/09/14 identified the problem "Risk for Suicide." The interventions to address the problem included the nursing intervention "Staff will provide reassurance and support during interactions to maintain a calm and safe environment for the patient for three (3) days."

3. Patient G3 was admitted on 11/12/14. The Master Treatment Plan dated 11/12/14 identified the problem "Continuity of Care." The interventions to address this problem include nursing intervention, "Nurse will provide patient and parent/guardian (if applicable) instructions regarding medication administrations and teaching, the social worker/case manage intervention "CM will verify placement appropriateness and acceptability within two (2) days from admission."

4. Patient G5 was admitted on 11/9/14. The Master Treatment Plan dated 11/9/14 documented the problem, "Suicidal Thoughts/Plans." The interventions to address this problem included the nursing intervention "staff will assess mood and depressive symptoms every shift."

5. Patient G6 was admitted on 9/23/14. The Master Treatment Plan dated 9/23/14 documented the problem, "Hallucinations," The interventions to address this problem included the nursing intervention, "staff will assess for severity of impairment in daily functioning every shift."

6. Patient G7 was admitted on 11/5/14. The Master Treatment Plan dated 11/5/14 documented the problem, "Paranoid and/or Delusional Thoughts/Behaviors." The interventions to address this problem included the nursing intervention, "staff will assess for signs and symptoms of paranoid or delusional thinking."

7. Patient G8 was admitted on 9/23/14. The Master Treatment Plan dated 9/23/14 listed the problem, "Hallucinations." The interventions to address this problem included the nursing intervention, "staff will assess for severity of impairment in daily functioning every shift."

B. Interview

In interview on 11/18/14 at 3:30 p.m., the Chief Nursing Officer acknowledged that the nursing interventions documented on the Master Treatment Plans of sample patients were vague and were not individualized.

ll. Treatment Interventions

A. Patient Findings

1. Patient G5 was admitted on 11/9/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G5 failed to attend 63% of his/her assigned groups. Review of the Special Observation Record which recorded patient location every 15 minutes, revealed that Patient G5 was listed as "In Group" (location key eight "8") only on two (2) occasions from 11/10/14-11/17/14 (11/17/14 at 1:30 p.m. and 1:45 p.m.). Review of the Master Treatment Plan revealed that Patient G5's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 2:30 p.m., Patient G5 stated that he/she did not go to groups because "I'm sleepy and depressed. They let me stay in bed most of the day except for smoke breaks."

In interview on 11/18/14 at 9:45 a.m., CBHT1 stated, "[Patient] doesn't attend many groups. He/she usually stays in bed."

In interview on 11/18/14 at 9:55 a.m., RN1 stated that Patient G5 "stays in [his/her] room."

During observation on the Secure Unit, Patient G5 was observed in bed, under the covers on 11/17/14 at 2:00 p.m. (Recreation Therapy Group in progress). Patient G5 was also observed in bed on 11/18/14 at 9:45 a.m. (Current Events Group in progress) and on 11/18/14 at 10:15 a.m. (Recreational Therapy Group in progress).

2. Patient G6 was admitted on 9/23/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G6 failed to attend 41% of his/her assigned groups. Review of the Special Observation Record revealed that Patient G6 was listed as "In Group" (location key eight "8") only on two (2) occasions from 11/10/14-11/17/14 (11/15/14 at 9:15 a.m. and 9:30 a.m.). Review of the Master Treatment Plan revealed that Patient G6's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 3:00 p.m., Patient G6 stated that he/she spent the day "smoking cigarettes, reading the Bible and watching tv." He/she further stated that the groups were not interesting and "they do the same things over and over."

In interview on 11/18/14 at 9:55 a.m., RN1 stated that Patient G6 was waiting to go to the State Hospital where he/she could get substance abuse treatment. RN1 further stated that Patient G6 did not go to groups very often.

During observations on the Secure Unit, Patient G6 was observed in bed, under the covers on 11/17/14 at 2:30 p.m. (Recreation Group in progress). Patient G6 was also observed in bed on 11/18/14 at 9:40 a.m. (Current Events Group in progress), at 10:15 a.m. (Recreation Group in progress) and at 2:30 p.m. (Recreation Group in progress).

3. Patient G7 was admitted on 11/5/14. Review of the Patient Assessment Report-Group Notes from 11/10/14-11/17/14 revealed that Patient G7 failed to attend 46.8 % of his/her assigned groups. Review of the Master Treatment Plan revealed that Patient G7's failure to attend groups had not been addressed by the treatment team.

In interview on 11/17/14 at 2:45 p.m., Patient G7 stated that he/she did not like the groups and didn't go to them. Patient G7 further stated that he/she spent a lot of time in bed.

In interview on 11/18/14 at 10:00 a.m., RN2 stated that Patient G7 was "disorganized." Patient G7 was on one (1) on one (1) observation and RN2 stated that the one (1) on one (1) staff sometimes took the patient to groups.

During observation on the Secure Unit, Patient G7 was observed in bed, under the covers on 11/17/14 at 11:15 a.m. (Goals Group in progress) and 2:45 p.m. (Recreation Group in progress).

B. Interview

1. In interview on 11/18/14 at 9:45 a.m., CBHT1 stated that if patients did not want to go to group the nursing staff could not "make them go."

Based on record review and staff interview it was determined that the facility failed to provide professional therapeutic staff that would design and implement structured therapeutic activities. This failure resulted in a lack of structured therapeutic groups/activities to assist the patient in meeting their treatment goals.

Findings include:

A. Record review

A review of medical records revealed an absence of individualized therapeutic activities for patients (G1, G2, G3, G4, G5, G6, G7, and G8). Instead the recreational activities placed on the unit schedules were provided by Recreational Therapy Assistants (RTAs) without consultation from a professional therapeutic activities staff member. The majority of the groups consisted of card games, bingo, coloring, social events with food, and other leisure activities.

B. Interview

In interview on 11/18/14 at 12:45 p.m., the supervisor for the RTAs stated that she was a Mental Health Counselor and did not have educational preparation in therapeutic activities. She further stated that the Music Therapist who had previously supervised the RTAs had resigned, but the facility had not replaced that position.