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Based on record review and interview, the facility failed to provide comprehensive inpatient psychiatric care in 1 of 1 departments surveyed (Inpatient Psychiatric).

Findings:
6 of 10 patients did not receive psychosocial services per policy. See tag C271.

The facility failed to provide a treatment plan with measureable goals and interventions to 10 of 10 patients. See tag C298.

The cumulative effect of these findings has the potential to adversely affect all 8 patients receiving care at the facility during the time of the survey.

Based on record review and interview, the facility failed to ensure psychosocial needs were assessed by a social worker for 6 of 10 patients reviewed (Patient #1, Patient #2, Patient #3, Patient #6, Patient #9, Patient #10).

Findings:

Facility policy "Interdisciplinary Assessment Overview" No. 03.002 states: "D. Psychosocial Assessment. The Social Worker or qualified therapist is responsible for ensuring the timely completion of all elements of the Psychosocial Assessment. The Psychosocial Assessment is initiated upon admission and completed within 72 hours of admission."

Facility policy "Elements of the Psychosocial Assessment" No. 03.006 states: "Psychosocial Assessments will be completed within 72 hours of admission for length of stay greater than 10 days and 48 hours for length of stay less than 10 days..."

Patient #1's medical record contains a psychosocial assessment dated 2/16/2016. The assessment was completed by a Registered Nurse, not a Social Worker. Patient #1 was not assessed or evaluated by social services at any time during the inpatient stay, from 2/16/2016 through 2/29/2016.

Patient #2's medical record contains a psychosocial assessment dated 2/12/2016. The assessment was completed by a Registered Nurse, not a Social Worker. Patient #2 was not assessed or evaluated by social services at any time during the inpatient stay, from 2/9/2016 through 2/29/2016.

Patient #3 received inpatient services from 1/27/2016 through 2/1/2016. There is no psychosocial assessment or social worker progress notes in Patient #3's medical record.

Patient #6 received inpatient services from 5/18/2016 through 5/20/2016. There is no psychosocial assessment in Patient #6's medical record.

Patient #9 received inpatient services from 3/23/2016 through 3/27/2016. There is no psychosocial assessment or social worker progress notes in Patient #9's medical record.

Patient #10 received inpatient services from 4/20/2016 through 4/22/2016. There is no psychosocial assessment in Patient #10's medical record.

During an interview on 6/21/2016 at 9:25 AM, Manager A stated the department's Social Worker "left" employment at the end of January, 2016. Social Worker C started working in March, 2016 but there was no social worker on staff in the interim. On 6/22/2016 at 10:05 AM, Manager A confirmed the dates in which there was not a social worker on staff as 1/31/2016 through 3/21/2016. Review of the facility's discharge patient list reveals there were a total of 26 inpatient discharges from 1/31/2016 through 3/21/2016. Manager A stated the department did not use any other social workers from the hospital or outpatient unit to help meet patient's psychosocial needs at that time.

Manager A stated the Psychosocial Assessment can be completed by "any licensed clinical staff" and is expected to be completed "within 72 business hours" or "3 business days excluding weekends and holidays."

During an interview on 6/21/2016 at 3:55 PM, Social Worker C stated the psychosocial assessments need to be started within 3 business days. C stated if a patient is admitted on a Wednesday, C would have until the following Monday to do the assessment.

During an interview on 6/22/2016 at 8:45 AM, Medical Director G stated there were "no concerns without a social worker."

During interviews on 6/22/2016 at 9:45 AM, Chief Clinical Officer D and Quality Director E stated they were not aware that the department did not have a social worker on staff from 1/31/2016 through 3/21/2016. Manager A stated the facility has 1 social worker on staff in the department, but there is no coverage available if the social worker is unavailable and there is no director of the service.

Based on record review and interview, facility staff failed to develop an individualized psychiatric treatment plan including measurable goals and interventions for 10 of 10 patients (Patient #1-10).

Findings:

Facility policy "Treatment Planning Process" No. 05-002 states: "L. Individual Treatment Plans are written based on the active problems identified...include the problem number, the problem name, evidenced by, related to, long-term goals, short-term goals and interventions by each discipline. N. Document the date that the long- or short-term goals have been resolved... O. Define short-term goals that will be indicators of movement towards the long-term goal on the Individual Treatment Plans. Short-term goals must be specific and measurable, representing steps toward reaching the long-term goal...P. Define specific interventions which comprise the treatment that will be utilized to help patient achieve short- and long-term goals on the Individual Treatment Plans. Include the frequency of each activity, ...which discipline will be responsible for implementation, focus of intervention, and when possible the name of person responsible. Treatment Plan Review Procedure: B. Record progress or lack of progress for each short-term goal. Determine the extent to which the interventions were implemented and the extent to which the goals were accomplished."

Patient #1 was admitted on 2/16/2016 with an admitting diagnosis of Dementia. Patient #1's Master Treatment Plan, dated 2/16/2016, identifies the following problems: 1. Elopement Risk, 2. Anxiety, 3. Altered Thought, 4. Infection-UTI [Urinary Tract Infection]. The plan does not include measurable and specific goals or interventions designed to assist Patient #1 in meeting goals. There is no documentation if the goals were met at the time of discharge 2/29/2016 and if problems were resolved.

Patient #2 was admitted on 2/9/2016 with an admitting diagnosis of Bipolar Disorder with Suicidal Ideation. Patient #2's Master Treatment Plan, dated 2/10/2016, identifies the following problems: 1. Alteration in Sleep, 2. Anxiety, 3. Altered Thought, 4. Fall Risk, 5. Self harm potential. Nursing Plan of Care notes on 2/9/2016 document a problem of Self Harm Potential; Goal: Patient will engage in structured activities and report a decrease in self harm thoughts; Outcome: Ongoing. An RN note on 2/16/2016 states: "Patient remains on line of sight observation at this time due to continued suicidal ideation." There is no documentation of interventions or progress toward the goal for the problem of Self Harm. Other problem goals are not labeled as short or long-term and there are no interventions included that are designed to assist patient in meeting goals.

Patient #3 was admitted on 1/27/2016 with an admitting diagnosis of Dementia. Patient #3's Master Treatment Plan, dated 1/28/2016, identifies the following problems: 1. Agitation, 2. Fall Risk, 3. Potential for Harm to Others, 4. Anxiety. There are no interventions identified in the treatment plan, and no responsible persons or disciplines identified.

Patient #4 was admitted on 4/11/2016 with an admitting diagnosis of Dementia with Hallucinations. Patient #4's Master Treatment Plan, dated 4/11/2016, identifies the following problems: 1. Fall Risk, 2. Altered Thought, 3. Agitation, 4. Anxiety, 5. Nutritional Deficit. Goals include: "Patient will demonstrate behavioral control that may permit increased functioning level" and "Patient will have an absence of or decrease in hallucinations/delusions/paranoia prior to discharge." The goals are not measurable and there are no interventions or responsible persons included in the plan.

Patient #5 was admitted on 6/6/2016 with an admitting diagnosis of Depression. Patient #5's Master Treatment Plan, dated 6/6/2016, identifies the following problems: 1. Altered Thought, 2. Anxiety, 3. Altered Mood, 4. Fall Risk, 5. Self harm potential. Alteration in mood goal is for patient to show a decrease in symptoms. Anxiety goal is for patient to participate in unit activities and social interactions with manageable anxiety level. The goals are not measurable and do not define the "manageable" anxiety level. There are no interventions in the plan to help patient meet outcome goals. There is no measurable progress toward goals documented.

Patient #6 was admitted on 5/18/2016 with an admitting diagnosis of Depression. Patient #6's Master Treatment Plan, dated 5/18/2016, identifies the following problems: 1. Alteration in mood, 2. Anxiety, 3. Self harm potential, 4. Altered thought. The plan does not include interventions assigned to responsible person or discipline.

Patient #7 was admitted on 6/13/2016 with an admitting diagnosis of Paranoid Schizophrenia. The Master Treatment Plan includes a problem of Agression/Poor Impulse Control. The goal of "Patient will not hurt self or others" is addressed by nursing staff as "ongoing" but does not include interventions or document baseline behaviors or progress toward goal.

Patient #8 was admitted on 6/3/2016 with an admitting diagnosis of Dementia. Patient #8's Master Treatment Plan includes problems of 1. Agitation, 2. Alteration in mood, 3. Alteration in thought, 4. Fall risk, 5. Alteration in sleep. The problems do not list interventions and no responsible persons or disciplines are identified. Nursing documentation does not include measurable and specific short or long-term goals.

Patient #9 was admitted on 3/23/2016 with an admitting diagnosis of Dementia. Patient #9's Master Treatment Plan includes problems of 1. Altered thought, 2. Fall risk, 3. Altered mood. The plan does not include measurable and specific goals or interventions designed to assist patient meeting goals.

Patient #10 was admitted on 4/20/2016 with an admitting diagnosis of Depression with Hallucinations. Problems identified in the Master Treatment Plan incude: 1. Altered thought, 2. Altered mood, 3. Fall risk. The plan does not include measurable and specific goals or interventions designed to help patient in meeting goals.

These findings were confirmed at the time of the review on 6/21/2016 between 9:00 AM and 3:30 PM with Manager A. Manager A stated on 6/21/2016 at 1:50 PM "we talk about interventions [sic] and go through every patient during a full review every week" and stated responsible staff are not documented on the treatment plan. On 6/22/2016 at 10:05 AM, Manager A stated "we know the treatment plans need to be revised."

Based on record review and interview, the facility failed provide discharge planning for 3 of 10 patients (Patient #1, Patient #2, Patient #3).

Findings:

Facility policy "Discharge Criteria" No. 02.003 states: "A patient is discharged from the Program based on the following criteria: A. If the treatment team determines that the patient has adequately accomplished the goals of treatment. B. If the patient's condition necessitates long-term, ongoing treatment, a transfer to an appropriate facility will be arranged...If a patient requests discharge without the treatment team's agreement and is not in need of involuntary admission...the patient shall be discharged against medical advice."

Facility policy "Discharge Planning and Continuing Care Overview" No. 10-0001 states: "Discharge planning begins upon admission and is the joint responsibity of the Attending Psychiatrist and the Clinical Social Worker/Nurse. Discharge planning is documented on the Master Treatment Plan...The Social Worker is responsible for the development and coordination of the discharge plan and safety plan. The Social Worker will coordinate family and community resources to provide optimum implementation of the discharge plan...Nursing staff is responsible for documenting the patient's condition and ambulatory status as well as escorting the patient and family from the unit."

Patient #1 was admitted to the facility on 2/16/2016 with a diagnosis of Major neurocognitive disorder due to Alzheimer's disease, probable, with behavioral disturbance. Patient #1's Master Treatment Plan dated 2/16/2016 documents under Discharge/Continuing Care: "Patient/Family Education Needs: Medication; Diagnosis/Disease Process; Coping Skills; Placement Options. Discharge Criteria: Consistent stabilization in mood; Reduction of target symptoms: elopement attempts; Services Needed after Discharge/Discharge Plan: Living Arrangements: Home vs. Assisted Living." Patient #1's medical record contains an initial nursing progress note dated 2/16/2016 at 7:45 AM stating: "Patient will most likely need placement at discharge. Goals for visit will be to reduce anxiety and allow patient to be in least restrictive environment." Patient #1 was discharged from the facility to home on 2/29/2016. There is no documentation of a discharge plan, or patient or family education in the medical record. There is no evidence that the patient's post-discharge needs were assessed and evaluated to determine the appropriateness of the patient's discharge to home.

Patient #2 was admitted as an inpatient on 1/30/2016 with depression and suicidal ideation. There is no documention in the medical record relating to discharge planning. Patient #2 was discharged to home on 2/4/2016 and readmitted on 2/9/2016, 5 days after discharge, with psychosis and suicidal ideation.

Patient #3 was admitted to the facility on 1/27/2016 with Major neurocognitive disorder, likely alzheimers type, with behavioral disturbance. The Master Treatment Plan, dated 1/28/2016 does not include any documention under Discharge/Continuing Care. There are no progress notes documenting any discharge planning activities. Patient #3 was discharged from the facility to home on 2/1/2016.

During an interview on 6/21/2016 at 3:55 PM, Social Worker C stated there is no formal discharge screening or evaluation, "we do what we feel is appropriate." Manager A stated all members of the interdisciplinary team are involved in discharge planning activities, but A was not aware of any review process to ensure that patient's post-discharge needs are being met.

Quality Director E stated on 6/22/2016 at 8:15 AM that the facility does not monitor discharge or readmission data from the inpatient psychiatric unit.

Based on record review and interview, the facility failed to provide quality oversight to 1 of 1 departments reviewed (Inpatient Psychiatric).

Findings:

Clinical records are not reviewed or audited as part of the quality program. See Tag C333.

Performance analysis and improvement activity is not provided as part of the quality program. See Tag C336.

The cumulative effect of these deficiencies has the potential to affect all patients receiving care in the Inpatient Psychiatric unit of this facility.

Based on record review and interview, the facility failed to review clinical records as part of the quality program in 1 of 1 department surveyed (Inpatient Psychiatric).

Findings:

The facility's "Performance Improvement Plan" for fiscal year 2016 states the plan will assess quality with consideration given to: "The effectiveness with which tests, procedures, treatments, and services are provided. The continuity of the services provided to the patient/resident with respect to other services, practitioners, and providers over time."

During an interview on 6/22/2016 at 10:05 AM, Manager A stated no review of the patient records was performed on a regular basis. Manager A was unaware of any quality review or oversight of the discharge planning services or the treatment plans developed for inpatients.

Program Director B stated on 6/22/2016 at 10:05 AM, Vice President F "came here a few months ago" and reviewed records. Program Director B stated B wasn't sure which components of the medical record were reviewed or why, but the F had sent a letter with "recommendations" pertaining to the facility's treatment plans. Manager A and Program Director B stated nothing had been initiated in response to the recommendations.

During an interview on 6/22/2016 at 8:45 AM, Medical Director G stated the clinical services provided in the inpatient psychiatric department were "all being monitored." Medical Director G stated department staff meets every morning to discuss patients and discharges but was unable to speak to any quality oversight or monitoring for potential gaps in care.

Based on record review and interview, the facility failed to perform quality and performance improvement activities in 1 of 1 department reviewed (Inpatient Psychiatric). This has the potential to affect all 8 patients recieving care in the department at the time of the survey.

Findings:

The facility's "Performance Improvement Plan" for fiscal year 2016 states: "The scope of performance improvement plan includes all services provided...Objectives. ...b. To collect data to monitor performance, systematically aggregate, analyze and display data. Information from data analysis is used to make changes that improve performance and patient/resident safety...e. To design new or modify processes well and to systematically measure and assess for improved patient/resident outcomes...Departmental Performance Improvement: The director of each department is responsible to continually assess and improve their services and departmental processes. Improvements are planned and designed using the PDSA [Plan-Do-Study-Act] model."

During an interview on 6/22/2016 at 8:15 AM, Chief Clinical Officer D stated oversight of the inpatient psychiatric department was contracted with an outside entity. Program Director B stated the facility received a quarterly quality report from the contracted entity. Review of the most recent report includes patient demographic data and outcome data and comparison to national aggregate data. During review of the quality report, neither Director B nor Manager A were able to speak to the degree in which the report had been used in analyzing patient outcome trends or developing potential performance improvement initiatives. Director B stated "this is the first I've really looked at this."

During an interview on 6/22/2016 at 8:15 AM, Quality Director E stated quality data is collected from each department monthly and reported to the Quality Council every 3 months. Director E stated the 2016 focus area for the inpatient psychiatric department was to improve patient satisfaction rates but was unable to provide baseline data or rationale behind the selection of patient satisfaction as a focus area of improvement. Quality Director E and Chief Clinical Officer D stated the facility was moving to a new vendor to provide patient satisfaction surveys, but no plan had been implemented to help improve ratings and no goals had been established.

During review of findings on 6/22/2016 at 9:00 AM pertaining to discharge planning and inpatient treatment plans, Program Director B, Manager A and Quality Director E confirmed that were no quality or performance improvement activities monitoring those patient services. At the time of the survey, Quality Director E had worked at the facility as the Quality Manager for 11 months. Per E, there have been "no performance improvement activities in the past 11 months" specific to the inpatient psychiatric department. Chief Clinical Officer D stated "we haven't been as involved" and "we weren't getting as much as we needed" from the contracted entity.