HospitalInspections.org

Based on document review and interview, the governing body failed to ensure monitors and standards for 1 service provided by a contractor (respiratory therapy) and 1 service directly provided by the facility (utilization review), as part of its comprehensive quality assessment and performance improvement (QAPI) program for calendar year 2015.

Findings include:

1. Review of the facility's QAPI program for calendar year 2015 indicated it did not include monitors and standards for the contracted service of respiratory therapy.

2. Interview of employee #A3, Director Inpatient & Primary Care, on 01-06-2016 at
4:00 pm, confirmed the above and no further documentation was provided prior to exit.

3. Review of the facility's QAPI program for calendar year 2015 indicated it did not include monitors and standards for the directly provided service of utilization review.

4. Review of the Medical Staff Meeting minutes of October 15, 2013, indicated this was the last time utilization review activities were reviewed as part of the facility's QAPI process.

5. Interview of employee #A2, Chief Executive Officer, on 01-04-2016 at 1:45 pm, confirmed the above regarding utilization review and no further documentation was provided prior to exit.

Based on document review and interview, the hospital failed to ensure a list of all contracted services in 1 instance.

Findings include:

1. On 01-04-2016, employee #A2, Chief Executive Officer, was requested to provide documentation of a list of all contracted services.

2. Interview of employee #A2 on 01-06-2016 at 2:30 pm, indicated there was no requested list and no other documentation was provided prior to exit.

Based on document review and interview, the hospital failed to ensure that a written notice of the facility decision related to an investigation was provided to the complainant, as required per facility policy, for 1 of 1 grievance reviewed (Complainant #56).

Findings Included:
1. Review of the policy Consumer Complaint, policy number I.D.6., last reviewed 3/2/15, indicated in item #7.: When the complainant has gone beyond the first level without satisfactory resolution to the complaint, the immediate supervisor shall document the nature of the complaint in writing...and send it to the Executive Director. In section 8., it reads: If the complainant has gone beyond the first level without satisfactory resolution of the complaint, the complaint then constitutes a grievance and the Executive Director will be notified... The Executive Director will review the complaint and attempts at resolution and prepare a written response to the consumer in an attempt to resolve the grievance.

2. Review of facility documents related to the complaint for patient #9, by family member #56, indicated:
A. A complaint was filed by family member #56 on 10/29/15 related to pt. #9 having "intellectual disabilities" and moderate to severe mental illness, and was "denied treatment multiple times". It was noted that the patient had suicidal ideations and the caller was the guardian, but not being allowed to see the patient.
B. Staff member #57, the Consumer Complaints officer, noted: I am conducting interviews with staff persons identified in caller's complaint, including the physicians, and all staff persons [#56, the complainant] identified in [their] telephone conversation with me. (No time or date of this note was written.)
C. It was noted that there was follow up with the Inpatient Unit Program Administrator (staff member P1), and with the patient's therapist on 11/3/15, 11/4/15 and 11/9/15, and that the psychiatrist was consulted (with no date given of this follow up conversation).
D. Staff member #57 documented having called the complainant back on 11/9/15 and that they were "still very vocal" and not satisfied with the resolution.

3. At 12:35 PM on 1/6/16, interview with the CEO (chief executive officer), staff member #51, confirmed that this staff member was notified of the continued dissatisfaction of the complainant related to the 10/29/15 complaint issues. This staff member went to the courthouse and met with APS (adult protective services) and the prosecutor to attempt to keep the patient out of jail, without success. There is no documentation by this staff member of their attempts at resolution to the complaint/grievance. No written notice was sent to the complainant with an explanation of the investigation process, efforts made to address their issues, and a final resolution by the facility.

Based on document review and interview, the facility failed to ensure that an order for restraint was obtained for 1 of 1 client, noted per incident reports, who was carried by staff to the quiet room (Client #9).

Findings Include:
1. Review of facility incident reports indicated that on 10/22/15 at 2:45 PM, Client #9 sat on the floor of the phone booth refusing to get out of the phone booth, and that the client "had to be carried out by staff and was taken to quiet room".

2. At 1:30 PM on 1/6/16, interview with staff members P2, the inpatient unit director, and #51, the chief executive officer, confirmed that no restraint order was received related to client #9 being carried by staff. It was not known that this would be considered a restraint, even though there were hands on the patient and normal movement was restricted.

Based on document review and interview, the facility failed to ensure that the attending physician was consulted as soon as possible after a restraint or seclusion event, if the attending physician did not order the restraint or seclusion, for 4 of 4 clients who had a restraint or seclusion episode (Clients #1, #3, #5 and #7).

Findings Include:
1. Review of the policy Nonviolent Crisis Intervention, policy number II.A.17, last reviewed 8/31/15, indicated there was nothing in the policy regarding the need to consult with/notify the attending physician of a restraint or seclusion for their client after such episode occurs.

2. Review of client medical records indicated:
A. Client #1 had a 4 point restraint on 9/12/15 ordered by physician #58. There was no documentation that the attending physician, #61, was notified/consulted regarding the restraint.
B. Client #3 had a 4 point restraint on 3/22/15 ordered by physician #59. There was no documentation that the attending physician, #61, was notified/consulted regarding the restraint.
C. Client #5 had 4 point restraints ordered on 2/6/15 by physician #59. There was no documentation that the attending physician, #61, was notified/consulted regarding the restraint.
D. Client #7 had a seclusion event on 1/24/15 ordered by physician #60. There was no documentation that the attending physician, #61, was notified/consulted regarding the restraint.

3. At 12:30 PM on 1/6/16, interview with staff member P2, the inpatient unit director, confirmed that:
A. Physician #61 is the attending physician for all clients admitted to the facility.
B. The facility policy does not address the requirement that the attending physician must be notified of all restraint or seclusion events of their clients, if these are ordered by other practitioners.
C. Patients #1, #3, #5 and #7 had orders for restraint or seclusion by other practitioners, than the attending physician, and did not have documentation of the attending physician (#61) being consulted, or notified, of these events.

Based on document review and interview, the facility failed to release clients from restraint or seclusion at the earliest time possible for 3 of 4 clients who were restrained/secluded (Clients #3, #5 and #7).

Findings Include:
1. Review of the facility policy Nonviolent Crisis Intervention, policy number II.A.17, last reviewed 8/31/15, indicated on page 5 in section P.: If the patient has been calm or sleeping for a period of up to two (2) hours, the nurse will awaken the patient to determine readiness for reduction/release...".

2. Review of client medical records indicated:
A. Client #3 had seclusion initiated and 4 point restraints applied at 12:20 PM on 5/3/15 with documentation at: 1:05 PM that indicated: Clt (client) laying on side in bed. appears to be resting; 1:20 PM that noted: Clt laying on side in bed. Appears to be asleep; 1:35 PM, Clt laying on side in bed appears to be asleep; at 2:05 PM, Resting quietly on side; 2:20 PM, Removed blanket from head. Resting quietly on side; at 3:05 PM Clt resting quietly on side and at 3:30 PM, Reports need to use restroom. Contracts for safety. Seclusion D/C's (discontinued) at this time.
B. Client #5 had 4 point restraints initiated at 3 PM on 2/6/15 with documentation: at 7:25 PM Client now in 3 pt. (point) restraints; at 7:40 PM client resting on side; 7:55 PM client resting on [their] back; 8:10 PM Clt resting on side; 8:25 PM, 8:40 PM, and 8:55 PM, Clt resting on his/her back; 9:10 PM and 9:25 PM Clt resting on his/her side; 9:26 PM Clt restraint DC (discontinued).
C. Client #7 was secluded at 4:40 AM on 1/24/15 and was noted as resting in bed stirring slightly at 9 AM; resting quietly in bed at 9:15 AM, 9:30 AM and 9:45 AM with seclusion D/C'd at 10 AM.

3. At 12:20 PM on 1/6/16, interview with staff member P2, the inpatient unit director, confirmed that:
A. The facility policy for restraint and seclusion allows clients to remain in restraint or seclusion up to 2 hours after they are resting, or sleeping quietly, which is not per federal regulations/requirements.
B. Clients #3, #5 and #7 were all documented as being quiet and no longer a threat to themselves or others, per documentation, and were not released at the earliest time possible.

Based on document review and interview, the facility failed to ensure that physicians had working knowledge of facility restraint and seclusion policies, and of the types of restraints used by staff, for 2 of 4 physicians (Physicians #58 and #59) who ordered restraint, and/or seclusion for 2 patients (client #1 and client #5).

Findings Include:
1. Review of the policy Nonviolent Crisis Intervention, policy number II.A.17, last reviewed 8/31/15, indicated there was nothing in the policy regarding training requirements for practitioners who order restraint, and/or seclusion, for patients.

2. At 11:00 AM on 1/6/16, interview with physician #58 confirmed that the practitioner had no training in non violent crisis intervention and the CPI (crisis prevention intervention) processes utilized at the facility.

3. Review of the training document for physician #59 indicated they were registered for the facility's "Management of Aggression" training 6/15/2009, but failed to attend then, or since, for training of the facility's non violent crisis intervention processes.

4. Review of patient/client medical records indicated physician #58 ordered a 4 point restraint for client #1 on 9/12/15, and physician #59 ordered a 4 point restraint for client #5 on 2/6/15.

5. At 10:45 AM and 12:35 PM on 1/6/16, interview with staff member P2, the inpatient unit director, confirmed that physicians #58 and #59 are ordering restraint and seclusion for clients and do not have documentation of training, or working knowledge, of the facility policy for restraint and seclusion, and for the types of restraint utilized.

Based on document review and interview, the facility failed to ensure the annual training in CPI (crisis prevention intervention) for 1 of 1 psychiatric technician, (N1) and 1 of 1 Director of the Inpatient unit, (P2).

Findings Include:
1. Review of the policy Nonviolent Crisis Intervention, policy number II.A.17, last reviewed 8/31/15, indicated under "IV. Procedure", in item E: Staff will be trained in acceptable physical control techniques.

2. Review of personnel files indicated:
A. Staff member N1, a psychiatric tech, last had CPI training on 5/13/14.
B. Staff member P2, the inpatient unit director, last had CPI 10/14.

3. At 2:10 PM on 1/4/16, interview with staff member #50, the human resources director, confirmed that staff member N1 failed to recertify in CPI in 2015, and was due in May of 2015 for annual CPI training, even though annual recertification is not addressed in the policy, it is an expectation of the facility.

4. At 3:45 PM on 1/4/16, interview with staff member P2 confirmed that they were delinquent in being recertified in CPI training in 2015 as annual recertification is a requirement of the facility, even though not addressed in policy.

Based on document review and interview, the facility failed to ensure the CPR (cardio pulmonary resuscitation) competence of one Program Administrator, staff member P1, and for 1 of 4 RNs (registered nurses), N4.

Findings Include:
1. Review of the job description for staff member P1 indicated under "Staff Development Activities" under item 6.: Keeps relevant skills current to continue working on the Inpatient Unit; e.g., CPR..., and in item 8.: CPR and First Aid trained - responds to medical emergencies.

2. Review of the job description for N4 indicated in the section "Staff Development Activities" in A. 5.: Completes training in CPR and First Aid.

3. Review of personnel files indicated:
A. Staff member P1 had CPR that expired 11/12/15.
B. Staff member N4 had CPR that expired 9/5/15.

4. At 3:45 PM on 1/4/16, interview with staff member #50, the human resources director, confirmed that staff members P1 and N4 lacked current CPR certification and were delinquent in being recertified.

Based on document review and interview, the hospital failed to ensure monitors and standards for 1 service directly-provided by the hospital (utilization review), and 1 service provided by a contractor (respiratory therapy), as part of its comprehensive quality assessment and performance improvement (QAPI) program for calendar year 2015.

Findings include:

1. Review of the facility's QAPI program for calendar year 2015 indicated it did not include monitors and standards for the directly-provided service of utilization review.

2. Review of the facility's QAPI program for calendar year 2015 indicated it did not include monitors and standards for the contracted service respiratory therapy.

3. Interview of employee #A2, Director Inpatient & Primary Care, on 01-05-2016 at 11:35 am, confirmed all the above and no further documentation was provided prior to exit.

Based on document review and interview, the facility failed to implement its policy for re-credentialing for 2 of 4 medical staff credential files reviewed.

Findings include:

1. Review of the Governing Board bylaws, Amended April 18, 2102, indicated appointment shall be made by the Board of Directors of the Center and shall be for a period of one (1) year or until the end of the fiscal year of the Board of Directors, whichever occurs sooner.

2. Review of 4 medical staff credential files indicated MD#1, (medical director), was last reappointed on 02-18-2014, and AH#1, nurse practitioner, was last reappointed on 08-14.

3. Interview of employee #A2, Chief Executive Officer, on 01-06-2106 at 11:45 am, confirmed the above and no other documentation was provided prior to exit.

Based on document review and interview, the nursing staff failed to follow the facility policy related to retrospective analysis, as per facility policy, for 4 of 4 clients restrained or secluded. (Clients #1, #3, #5, and #7.)

Findings Include:
1. Review of the policy Nonviolent Crisis Intervention, policy number II.A.17, last reviewed 8/31/15, indicated on page 4 in item G.: As soon as possible, but within 24 hours of the seclusion or seclusion and restraint process, a retrospective analysis is to be conducted by as many of the involved staff members as possible.

2. Review of client medical records, related to restraint and seclusion, indicated:
A. Client #1 had 4 point restraints initiated at 11:55 AM on 9/12/15 and had no respective analysis note completed.
B. Client #3 had 4 point restraints initiated at 8:15 AM on 3/22/15 and lacked a respective analysis note; had a 2 point restraint event on 4/15/15 at 1:00 PM with the respective analysis note dated as 5/7/15; and had a seclusion episode on 5/3/15 that had a respective analysis note dated 5/22/15. There was no documentation in the notes as to which staff attended, to determine if staff who were involved were in attendance at the respective analysis debriefings.
C. Client #5 had 4 point restraints applied at 8:35 AM and 3:00 PM on 2/6/15, was secluded at 9:25 AM on 2/7/15, and was secluded at 8:40 PM on 2/15/15. The respective analysis note reviewed was dated 2/12/15 and addressed the 2/6/15 and 2/7/15 events. The 2/15/15 seclusion had no respective analysis note documented.
D. Client #7 was secluded at 4:40 PM on 1/24/15 and a respective analysis note documented on 1/29/15.

3. At 10:45 AM on 1/6/16, interview with staff member P2, the inpatient unit director, confirmed that the respective analysis notes were not completed for all of the restraint, or seclusion, events that occurred for clients #1, #3, #5, and #7,within 24 hours of the episodes, and that documentation that was completed lacked noting which of the staff involved in the events were present at the respective analysis meetings, as required by facility policy.

Based on document review and interview, the facility failed to ensure documentation of the qualifications of nursing staff related to in and out catheterization, for the procurement of urine specimens, and in the insertion and care of indwelling (Foley) catheters.

Findings Include:
1. Review of facility policies indicated there was no policy related to the process of acquiring a urine specimen by in and out catheterization of a patient, nor was there a policy related to how the facility would document the skills competency if nursing staff in acquiring catheterized urine specimens, or in the insertion of an indwelling catheter.

2. Review of employee files for RNs (registered nurses) N3, P4, P5 and P6 and LPN (licensed practical nurse) P3, lacked any documentation of skills competency in the insertion, and care of, Foley catheters, or in the in and out catheterization process for obtaining urine specimens.

3. At 10:30 AM on 1/5/16, interview with the infection practitioner, P2, confirmed that:
A. There are currently no patients on the unit who have a Foley catheter.
B. The facility performs in and out catheterization of patients for obtaining urine specimens for testing.
C. The facility accepts patients with an indwelling Foley catheter.
D. There is no policy related to the insertion and care of Foley catheters, or related to the obtaining of catheterized urine specimens.
E. There is no skills competency done for nursing staff related to in and out catheterization, or for the insertion and care of Foley catheters.

Based on observation, the facility failed to properly store medical records in a location where they are protected from fire and water damage in 1 instance.

Findings include:

1. On 01-04-2016 at 2:00 pm, in the presence of employees #A2, Chief Executive Officer, #A3, Director Inpatient & Primary Care, and #A9, Maintenance Coordinator, it was observed in the secured patient medical records storage area, patient medical records were stored in 2 separate sections consisting of 7 levels of U-shaped shelving. It was also observed all the shelving was open, and that there was no manner of protection to the exposed records to any fire or water damage.

Based on document review and interview, the facility failed to have a policy, medical staff bylaw, or medical staff rules and regulations, in regard to who can accept a telephone or verbal order and what the authentication requirements, by the ordering practitioner, were for 4 of 4 clients (Clients #1, #3, #5 and #7).

Findings Include:
1. Review of facility policies indicated there was no policy related to verbal/telephone orders and authentication expectations.

2. Review of the medical records for clients #1, #3, #5 and #7 indicated:
A. Client #1 had a verbal order for Ativan 2 mg on 9/12/15 that was authenticated, and had verbal orders for Haldol, Cogentin, and Ativan on 9/11/15 that was authenticated, but both orders lacked a date and time of authentication by the physician.
B. Client #3 had verbal orders on 5/2/15 for Zyprexa and again on 5/3/15 for Zyprexa with both authenticated without a date and time of authentication.
C. Client #5 had telephone orders on 2/19/15 to hold Estrace, and on 2/20/15 a verbal order clarification for Benadryl, with both orders authenticated without a date and time of authentication.
D. Client #7 had verbal orders related to Harvoni on 1/24/15, and for Advair on 1/25/15, that were authenticated but lacked a date and time of the authentication by the practitioner.

3. At 1:30 PM on 1/5/16, interview with staff members #51, the chief executive officer, and P2, the inpatient unit director, confirmed that there was no policy, no medical staff bylaws, and no medical staff rules and regulations regarding who is allowed to accept telephone and verbal orders and what the authentication requirements are by the ordering practitioner.

Based on document review and interview, the facility failed to have policies or guidelines in place related to the appropriate indications for urinary (Foley) catheters, and measures to take for removal as soon as possible, to decrease the possibility of infection.

Findings Include:
1. Review of facility policies indicated there was none related to appropriate indications for a Foley catheter, or the monitoring of patients with Foleys, to ensure they are discontinued as soon as possible.

2. At 10:30 AM on 1/5/16, interview with staff member P2, the infection practitioner, confirmed that:
A. Patients may be admitted with Foley catheters in place.
B. There is no policy related to the appropriateness of a Foley, and daily assessment needed to determine the continued need of a Foley for patients.

Based on interview, the facility failed to ensure a policy describing which employees were authorized to have access to locked medication areas in 1 instance.

Findings include:

1. On 01-04-2016 at 11:30 am, employee #A2, Chief Executive Officer, was requested to provide documentation describing which employees were authorized to have access to locked medication areas.

2. Interview of employee #A3, Director Inpatient and Primary Care, on 01-06-2016 at
3:10 pm, indicated there was no such policy and no other documentation was provided prior to exit.

Based on interview, the facility failed to ensure a policy for reporting abuses and losses of controlled substances in 1 instance.

Findings include:

1. On 01-04-2016 at 11:30 am, employee #A2, Chief Executive Officer, was requested to provide documentation for reporting abuses and losses of controlled substances.

2. Interview of employee #A3, Director Inpatient and Primary Care, on 01-06-2016 at
3:20 pm, indicated there was no such policy and no other documentation was provided prior to exit.

Based on Life Safety Code (LSC) survey, Community Mental Health Center was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

The Community Mental Health Center is located on the non sprinklered first floor, East Wing, of a three story, partially sprinklered hospital with a basement of Type I (332) construction. There is a 2 hour fire separation wall between the hospital and the Community Mental Health Center. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors, and hard wired smoke detectors in all patient sleeping rooms. The facility has a capacity of 16 and had a census of 4 at the time of this survey.

Based on LSC survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure 18 photoelectric smoke detectors, 6 audible/visual devices, 1 fire alarm panel and 8 manual pull station boxes, which were all fire alarm system components, were functional tested annually and the results of such testing listed clearly on inspection reports to identify all devices had been tested and failed to ensure 18 of 18 smoke detectors were tested for sensitivity every two years (see K 051).

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 and interview, the facility failed to ensure 18 photoelectric smoke detectors, 6 audible/visual devices, 1 fire alarm panel and 8 manual pull station boxes, which were all fire alarm system components, were functional tested annually and the results of such testing listed clearly on inspection reports to identify all devices had been tested and failed to ensure 18 of 18 smoke detectors were tested for sensitivity every two years.

Findings:

1. Record review on 01/21/16 at 9:35 a.m. with DIS#1, the Director of Inpatient Services,
noted there were no annual fire alarm system inspection records to review to indicate all fire alarm system devices and components had been annually functional tested for the past year.

2. Interview with DIS#1 on 01/21/16 at 10:45 a.m. indicated the facility is contracted to have an annual fire alarm system inspection conducted, but the annual fire alarm system inspection was not conducted for the year 2015. This was verified by DIS#1 at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.

3. Record review on 01/21/16 at 9:50 a.m. with DIS#1 noted there were no records available for review to indicate the eighteen photoelectric smoke detectors throughout the facility had been tested for sensitivity over the past two years.

4. Interview with DIS#1 on 01/21/16 at 10:50 a.m. indicated there is no smoke detector sensitivity test records available for review. This was verified by DIS#1 at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.

Based on document review and interview, the infection control committee failed to ensure the infection practitioner had on going education and training related to infection control practices, and the infection control practitioner failed to ensure that a policy was created relevant to construction, renovation, maintenance, demolition, and repair of the facility and the requirement for an ICRA (infection control risk assessment).

Findings Include:
1. Review of the documents provided that listed on going education and training for staff member P2, the infection practitioner, indicated there was no training in 2014 and only a 1 hour webinar viewed/attended 5/20/15. (The last documented webinar series (3) in 2013 were in March).

2. At 12:20 PM on 1/6/16, interview with staff member P2 confirmed that only a one hour webinar has been attended since March 2013, as on going education/training toward the infection practitioner position.

3. Review of facility policies and procedures indicated there was no policy related to completing an ICRA for any construction, renovations, maintenance, demolition, or repair within the facility, to assure that infection practices are maintained.

4. At 9:30 AM on 1/5/16, interview with the infection practitioner, P2, confirmed that the facility had no policy related to infection practices and monitoring of any facility construction, and the need for an ICRA.

Based on document review, observation, and interview, the infection control officer failed to provide documentation of pest control service in 1 instance; failed to utilize a risk assessment to prioritize the selection of infection quality indicators related to infection prevention and control; failed to ensure that systems were in place to designate patients known to be colonized or infected with a targeted MDRO (multi drug resistant organism), failed to indicate how notification to receiving facilities and personnel will occur prior to the transfer of such patients to other facilities, and failed to show a process for the identification of colonized or infected patients with target MDROs are placed on Contact Precautions; failed to ensure the implementation of the facility policy related to TB (tuberculosis) testing for 1 medical records director (P3), 1 of 1 psych tech (N1), and for 2 of 2 RNs (registered nurses) hired in 2014 (N3 and P4); failed to implement facility policy related to Hepatitis B for 2 of 4 RNs (P5 and P6); failed to ensure that medications were not prepared within 36 inches of a handwashing sink; failed to implement the infection control plan in regard to an annual review of housekeeping products; failed to ensure that floors were disinfected with an EPA (environmental protection agency) registered disinfectant per facility policy; failed to ensure that EVS (environmental service) employees followed manufacturer's instructions for kill/dwell time of a product when cleaning; failed to ensure that mop heads and cleaning cloths were laundered at least daily and in an appropriate method; and failed to ensure a policy was created related to the expectations of nursing in administering an injection, and the failure to wear gloves when giving a TB test by LPN (licensed practical nurse) P3.

Findings Include:

1. On 01-04-2016 at 11:30 am, employee #A2, Chief Executive Officer, was requested to provide documentation of evidence of pest control service. No documentation was provided prior to exit.


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Based on document review, observation, and interview, the infection control practitioner failed utilize a risk assessment to prioritize the selection of infection quality indicators related to infection prevention and control; failed to ensure that systems were in place to designate patients known to be colonized or infected with a targeted MDRO (multi drug resistant organism), failed to indicate how notification to receiving facilities and personnel will occur prior to the transfer of such patients to other facilities, and failed to show a process for the identification of colonized or infected patients with target MDROs are placed on Contact Precautions; failed to ensure the implementation of the facility policy related to TB (tuberculosis) testing for 1 medical records director (P3), 1 of 1 psych tech (N1), and for 2 of 2 RNs (registered nurses) hired in 2014 (N3 and P4); failed to implement facility policy related to Hepatitis B for 2 of 4 RNs (P5 and P6); failed to ensure that medications were not prepared within 36 inches of a handwashing sink; failed to implement the infection control plan in regards to an annual review of housekeeping products; failed to ensure that floors were disinfected with an EPA (environmental protection agency) registered disinfectant per facility policy; failed to ensure that EVS (environmental service) employees followed manufacturer's instructions for kill/dwell time of a product when cleaning; failed to ensure that mop heads and cleaning cloths were laundered at least daily and in an appropriate method; and failed to ensure a policy was created related to the expectations of nursing in administering an injection, and the failure to wear gloves when giving a TB test by LPN (licensed practical nurse) P3.

Findings Include:
1. At 12:30 PM on 1/6/16, interview with staff member P2, the infection practitioner, confirmed that:
A. No infection control risk assessment is completed to determine and prioritize quality indicators related to infection prevention and activities.
B. There are no MDRO policies and MDRO clients are not tracked or monitored. Clients are not placed in contact precautions. Patients with an infection would maintain a "3 foot" space between themselves and others and staff maintains universal precautions with all patients. There is no policy related to how receiving facilities would be notified of MDRO patients, as the facility does not track these.

2. Review of the policy in effect when N1, N3 and P4 were hired, policy number III.A.9, "Employee Health Clearance", with a review date of 3/2/15, indicated in section "IV. Procedure": At the time of employment and annually thereafter, each employee working the Inpatient...will have a tuberculin skin test.

3. Review of employee files indicated:
A. The medical records director, P3, had no documentation in the file that a TB test was given at the time of hire.
B. Psych tech N1 was hired 4/22/14 and did not have a facility placed TB test until 5/20/15.
C. RN N3 was hired 4/22/14 and had the first facility placed TB test on 9/6/15.
D. RN P4 was hired 6/10/14 and had the first TB test placed by the facility on 11/21/15.

4. At 2:30 PM on 1/4/16, interview with staff member P2, the infection practitioner, confirmed that:
A. TB tests from previous employment were accepted at the time of hire for N1, N3 and P4 instead of doing TB tests upon hire
B. The facility policy does not indicate that an outside TB test may take the place of one that is to be done at the time of hire.
C. The expectation, even though not in policy, is that a TB test will be done before, or on, the first day of hire.

5. Review of the policy Bloodborne Pathogen Exposure Control, policy number I.D.12, last reviewed 11/24/14, indicated in section VII. Hepatitis B Vaccination: A. Hepatitis B Vaccine 1. Employees who have occupations exposure will be provided...Hepatitis B vaccine...7. All employees, whether they accept or decline the Hepatitis B vaccination, will be required to sign a statement.

6. Review of personnel files indicated RN P5 was hired 3/9/13 and had no Hepatitis B form in their file, and RN P6 was hired 4/28/15 and had no Hepatitis B form in their file.

7. At 10:05 AM on 1/5/16, interview with staff member #50, the human resources director, confirmed that forms related to Hepatitis B could not be found for RNs P5 and P6.

8. At 9:45 AM on 1/5/16, while observing the preparation of PPD (purified protein derivative) solution for TB test administration, it was observed that the nurse performed hand hygiene in the sink beside the counter where the medication was prepared, and that this was within 36 inches (was 6 to 12 inches) of the sink.

9. Review of the Infection Control Policy and Plan, policy number I.D.16, last reviewed on 5/18/15, indicated on page 4, in item 5., The Infection Control Committee shall, on an annual basis, invite the Environmental Coordinator to review cleaning procedures, products and equipment needs with the Committee.

10. Review of the Infection Control Committee meeting minutes for 2014 and 2015 indicated there was no documentation of the Infection Control Committee's review of housekeeping products.

11. At 12:30 PM on 1/6/16, interview with the infection preventionist, P2, confirmed that none of the meeting minutes indicated the EVS supervisor provided a list of cleaning products to the committee for review.

12. Review of the EVS policy related to "Patient Rooms", no policy number (noted as page 14), last reviewed on 10/14, indicated: All cleaning shall be done using a germicidal detergent solution.

13. Review of the inpatient unit policy Room Cleaning - After Patient Discharge or Room Change, "page" R -3, last reviewed 8/5/15 indicated there was no instruction to nursing staff related to the disinfection of the floor of the room with the terminal cleaning process.

14. At 9:05 AM on 1/5/16, observation and interview with housekeeping staff member P7 confirmed that Ammonia water was used to clean patient room floors on a daily basis.

15. At 9:10 AM on 1/5/16, interview with the EVS manager, staff member #55, confirmed that the manufacturer for the new floors, (completed 11/14), recommended the use of Ammonia to clean floor surfaces to protect the new flooring, rather than a disinfectant solution.

16. At 9:30 AM on 1/5/16, interview with the infection practitioner, P2, confirmed that the current EVS policy indicated a disinfectant would be used on floor surfaces, the nursing staff terminal cleaning policy does not address the need to disinfect floors, and the use of Ammonia water is not sufficient to kill any organisms that might be on patient room floors.

17. At 9:10 AM on 1/5/16, interview with staff member P7, a housekeeper, confirmed that the cleaning product used on high touch surfaces (Virex TB) had a 1 minute kill time for Hepatitis B, a 5 minute kill time for TB and a 10 minute kill time of Hepatitis A. The staff member confirmed that they spray the product on and wipe it off. No wait time was mentioned in their explanation.

18. At 11:20 AM on 1/5/16, while on the inpatient unit waiting to observe meal tray prep for the clients, it was observed that housekeeping staff member #62 was spraying the Virex TB product on a doorway/door frame and immediately wiped it off with no observed wait, or kill, time noted.

19. At 9:05 AM and 9:20 AM on 1/5/16, EVS staff member P7 confirmed that:
A. Mop heads are double dipped in the floor cleaning solution, the cleaning solution is changed when needed, one or two mop heads are used daily in cleaning of patient rooms and the whole of the inpatient unit.
B. Mop heads and cleaning cloths are washed once a week, on Tuesdays, in the same washing machine as the client's use to launder their clothing.
C. 1/2 to 1 cup of bleach is used in the washing machine, depending on the size of the load.
D. It was unknown what the CDC (center for disease control and prevention) laundry recommendations were, and if the bleach solutions they are using are appropriate to destroy organisms that may be picked up during the cleaning process.

20. At 9:30 AM on 1/5/16, interview with the infection practitioner, P2, confirmed that this staff member does not monitor the housekeeping staff regarding cleaning and laundry processes as they may relate to infection control.

21. Review of the Infection Control Policy and Plan, policy number I.D.16, last reviewed on 5/18/15, indicated on page 4., Sterile techniques must be employed by staff members who administer injectable medications to consumers.

22. Review of the 2014 10th Edition of the Lippincott Manual of Nursing Practice indicated on page 1023, for Intradermal Skin Testing, in the "implementation phase" that: "...While wearing gloves, place syringe at a 10 to 15 degree angle...".

23. At 9:45 AM on 1/5/16, in the observation of the administration to a staff member of an intradermal TB test by LPN P3, it was noted that the LPN failed to wear gloves when administering the test.

24. At 10:30 AM on 1/5/16, interview with staff member P2, the infection practitioner, indicated there is no facility policy related to injection procedures/processes and requirements, but it is expected that gloves would be worn to administer injections.

Based on document review and interview, the facility discharge planning evaluation did not include an assessment of whether the patient would require specialized medical equipment and home and/or physical environment modifications for 4 of 5 (#MRA2, #MRA3, #MRA4 and #MRA5) patient medical records reviewed.

Findings include:

1. Review of 5 medical records indicated medical records #MRA2, #MRA3, #MRA4 and #MRA5, did not include as part of the discharge planning evaluation, an assessment of whether the patient would require specialized medical equipment and home and/or physical environment modifications.

2. Interview of employee #A2, Chief Executive Officer, on 01-05-2016 at 3:20 pm, confirmed for #MRA2, there was no documentation for an assessment of whether the patient would require specialized medical equipment and home and/or physical environment modifications and no other documentation was provided by exit.

3. Interview of employee #A3, Director Inpatient & Primary Care, on 01-06-2016 at
9:55 am, confirmed for #MRA3, there was no documentation for an assessment of whether the patient would require specialized medical equipment, and home and/or physical environment modifications and no other documentation was provided by exit.

4. Interview of employee #A3, on 01-06-2016 at 10:15 am, confirmed for #MRA4, there was no documentation for an assessment of whether the patient would require specialized medical equipment, and home and/or physical environment modifications and no other documentation was provided by exit.

5. Interview of employee #A3, on 01-06-2016 at 10:35 am, confirmed for #MRA5, there was no documentation for an assessment of whether the patient would require specialized medical equipment, and home and/or physical environment modifications and no other documentation was provided by exit.

Based on document review and interview, the facility failed to provide the patient at discharge, with a clear indication of changes from the patient's pre-admission medications, to those after discharge, for 4 (#MRA2, #MRA3, #MRA4 and #MRA5) of 5 patient medical records reviewed.

Findings include:

1. Review of 5 patient medical records indicated medical records #MRA2, #MRA3, #MRA4 and #MRA5 did not indicate at discharge, a clear indication of changes from the patient's pre-admission medications to those after discharge and no other documentation was provided prior to exit.

2. Interview of employee #A2, Chief Executive Officer, on 01-05-2016 at 3:25 pm, confirmed there was not a clear indication of changes, from the patient's pre-admission medications to those after discharge for #MRA2 and no other documentation was provided prior to exit.

3. Interview of employee #A3, Director Inpatient & Primary Care, on 01-06-2016 at
10:05 am, confirmed there was not a clear indication of changes, from the patient's pre-admission medications to those after discharge for #MRA3 and no other documentation was provided prior to exit.

4. Interview of employee #A3, on 01-06-2016 at 10:20 am, confirmed there was not a clear indication of changes, from the patient's pre-admission medications to those after discharge for #MRA4 and no other documentation was provided prior to exit.

5. Interview of employee #A3, on 01-06-2016 at 10:40 am, confirmed there was not a clear indication of changes, from the patient's pre-admission medications to those after discharge for #MRA5 and no other documentation was provided prior to exit.

Based on medical record review and staff interview it was determined that for four (4) of four (4) patients their Psychosocial Assessments failed to include a psychosocial formulation for the material gathered and failed to disclose the patient specific social work role in treatment and discharge planning. This failure results in the treatment team not having a current baseline assessment of social functioning for these patients in order to establish treatment goals and interventions and to know what efforts the social work staff are proposing to accomplish in treatment and discharge planning. (Patients A1, A2, A3 and A4)

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychosocial Assessment dated 1/04/2016 stated as the social functioning conclusion or formulation "Client will benefit from ongoing psychiatric care, including medication management, and psychotherapy to address ongoing depression, suicidal ideation, and the learning of new and effective coping skills". No patient specific social service role was described.

2. Patient A2: The Psychosocial Assessment dated 1/02/2016 stated "He will benefit from psychiatric evaluation. He will benefit from continued psychoeducation concerning stress management and positive coping skills". No patient specific social service role was described for discharge planning. This Psychosocial Assessment was done by an Activity therapist staff member.

3. Patient A3: The Psychosocial Assessment dated 1/02/2016 stated as the psychosocial formulation of the current baseline social functioning "He will benefit from further psychiatric evaluation and care. He will benefit from psychoeducation concerning stress management and utilize positive coping skills. He will benefit from psychotherapy". This assessment was done by an Activity therapist staff member.


4. Patient A4: The Psychosocial Assessment dated 1/02/2016 stated "He will benefit from psychiatric evaluation. He will benefit from medically supervised detoxification. He will benefit from psychoeducation concerning ways in which to abstain from substances. He will benefit from psychotherapy to aid in maintaining sobriety". This assessment was done by an Activity therapist staff member.

II. Staff Interview:

1. On 1/05/2016 at 10:55 AM the Director of Social Work was interviewed. She was shown the four (4) Psychosocial Assessments described in Section I above. She agreed that there was not present a psychosocial formulation of current baseline functioning. When Psychosocial Assessments for those patients had been done by Activity staff members, the Director agreed that there was no documented evidence of Social Work supervision present.

2. On 1/04/2016 at 2:15PM the facility's Program Administrator told the surveyor "Not all of them (Psychosocial Assessments) are reviewed by a Social Worker".

Based on medical record review and staff interview it was determined that Psychiatric Evaluations for four (4) of four (4) patients failed to describe personal assets in a descriptive manner. This failure results in the treatment team not being able to choose treatment modalities that might utilize the patient's attributes in therapy. (Patients A1, A2, A3 and A4)

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 1/02/2016 stated as the sole patient asset "relatively healthy".

2. Patient A2: The Psychiatric Evaluation dated 12/31/2016 stated as the sole patient asset "my family".

3. Patient A3: The Psychiatric Evaluation dated 12/31/2016 stated as the sole patient asset "my family".

4. Patient A4: The Psychiatric Evaluation dated 1/01/2016 stated as the sole patient asset "my family".

II. Staff Interview:

On 1/05/2016 at 2:50PM the facility's clinical director was interviewed. He was shown the findings described in Section I above. He agreed the assets as described did not reflect attributes within the patient that could potentially be utilized in therapeutic endeavors.

Based on record review and interview, the facility failed to provide a treatment plan that delineated short term patient centered goals based on the individual patient needs and/or problem behaviors requiring hospitalization for four (4) of four (4) sample patients (A1, A2, A3 and A4). The short term goals were not specific or measurable and merely described routine hospital functions. This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions and may prolong hospital stays beyond the resolution of the behaviors requiring admission.

Findings include:

I. Record Review

1. Patient A1 (Master Treatment Plan dated 1/3/15) had the following short term goals for the identified problem, "Thoughts of self-harm [and] suicide":

a. "Be safe on the unit. Have a written safety plan by 1/6/15."

b. "Attend daily groups [and] provide daily [treatment] goals."

c. "Demonstrate a more euthymic mood [with] no thoughts of self-harm by the time of [discharge]."

These goals were not specific to the individual patient and described routine, generic hospital functions.

2. Patient A2 (Master Treatment Plan dated 1/1/16) had the following short term goals for the identified problem, "Risk for suicide":

a. "Remain safe."

b. "Make a no suicide contract [every day] until [discharge]."

c. "Remain safe while in the [inpatient unit] with the aid of nursing interventions and support."

These goals were not specific to the individual patient and described routine, generic hospital functions.

3. Patient A3 (Master Treatment Plan dated 1/1/16) had the following short term goals for the identified problem, "Risk for Suicide":

a. "Complete his safety contract by day 2."

b. "Contract for no self-harm [every] shift until discharge."

c. "Remain safe while in the [inpatient unit]."


4. Patient A4 (Master Treatment Plan dated 1/1/16) had the following short term goals for the identified problem, "Risk for Suicide":

a. "Contract for no self-harm [every] shift until [discharge]."

b. "Remain safe on the [inpatient unit] throughout hospitalization."

c. " Complete safety plan by day 3. "

These goals were not specific to the individual patient and described routine, generic hospital functions.

II. Interview:

On 1/5/16 at 2:05 P.M., the Director of Nursing stated, "Yes, I agree. The goals are all the same."

Based on record review and interview, the facility failed to provide individualized treatment interventions for four (4) of four (4) sample patients (A1, A2, A3, and A4). This deficiency resulted in a failure to provide a basis for purposeful, directed treatment and to plan revisions based on individual patient needs and assessments.

I. Record Review:

1. Patient A1 (Master Treatment Plan dated 1/3/16) had the following nursing and social work interventions for the short term goals: "Be safe on the unit. Have a safety plan by 1/6/16. Attend daily groups [and] provide daily [treatment] goals. Demonstrate more euthymic mood [with] no thoughts of self-harm by the time of [discharge]."

Nursing Interventions

a. " Provide for general precautions."

b. "Encourage daily structure."

c. "Group attendance. Daily [treatment] goals."

d. "Assess [client's mood [and] cognition bid [twice daily] [and] prn [as needed]."

Social Work Interventions

a. "Complete psychosocial assessment within 72 hours of admission."

b. "Provide opportunity for daily group therapy."

c. "Assist with discharge planning."

These interventions were not individualized and were general hospital functions.

2. Patient A2 (Master Treatment Plan dated 1/1/16) had the following nursing and social work interventions for the short term goals: "Remain safe while in the [inpatient unit]. Make a no suicide contract [every] day until [discharge]. Remain safe while in the [inpatient unit] with the aid of [nursing] interventions [and] support."

Nursing Interventions

a. "Obtain a no self-harm contract [every] shift until [discharge]".

b. "Assist [client] in completing his safety plan by day 3."

c. "Encourage [client] to talk about his feelings and problems solve alternatives."

Social Work Interventions

a. "Complete psychosocial assessment within 72 hours of admission."

b. "Provide opportunity for daily group therapy."

c. "Assist with discharge planning."

These interventions were not individualized and were general hospital functions.

3. Patient A3 (Master Treatment Plan dated 1/1/16) had the following nursing and social work interventions for the short term goals: "Complete safety contract by day 2. Contract for no self-harm [every] shift until [discharge]. Remain safe while in the [inpatient unit]."

Nursing Interventions:

a. "Obtain a no self-harm contract [every] shift until [discharge]."

b. "Assist [client] in completing safety contract [and] plan by day 2."

c. "Encourage [client] to talk about feelings and problem solve alternatives."

Social Work Interventions:

a. "Assist with discharge planning."

b. "Complete psychosocial assessment within 72 hours of admission."

These interventions were not individualized and were general hospital functions.

4. Patient A4 (Master Treatment Plan dated 1/1/16) had the following nursing and social work interventions for the short term goals: "Contract for no self-harm [every] shift until [discharge]. Remain safe on the [inpatient unit] throughout hospitalization. Complete safety plan by day 3."

Nursing Interventions:

a. "Assist [client] in completing safety plan by day 3."

b. "Obtain suicide contract [every] shift until [discharge]."

c. "Encourage [client] to talk about feelings and problem solve alternatives."

Social Worker Interventions:

a. "Complete psychosocial assessment within 72 hours of admission."

b. "Provide opportunity for daily group therapy."

c. "Assist with discharge planning."

These interventions were not individualized and were general hospital functions.
II. Interviews

1. On 1/5/16 at 2:05 PM the Director of Nursing, stated, "I can see that the interventions are things that we do for everyone."

2. On 1/5/16 at 2:15 PM the Director of Social Work agreed that the interventions were generic and not patient specific.

Based on document review and interview, the facility failed to ensure appropriate discipline specific clinical and administrative supervision for nursing and social work staff. This deficiency resulted in professional staff not receiving appropriate clinical guidance which has the potential of compromising patient care.

Specifically, the facility failed to:

I. Provide nursing staff with appropriate discipline specific supervision. See B148 section II

II. Provide social work staff with appropriate discipline specific supervision. See B152

Based on medical record review and staff interview it was determined that the clinical director failed to monitor the adequacy of Psychiatric Evaluations with regard to patient specific assets and failed to monitor the treatment planning process to ensure that Treatment Plan goals and modalities were patient specific and not generic discipline functions. (Patients A1, A2, A3 and A4)

The findings include:

A .Psychiatric Evaluations lacking appropriate assessments of patient assets:

Based on medical record review and staff interview it was determined that Psychiatric Evaluations for four (4) of four (4) patients failed to describe personal assets in a descriptive manner. This failure results in the treatment team not being able to choose treatment modalities that might utilize the patient's attributes in therapy. (Patients A1, A2, A3 and A4)

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 1/02/2016 stated as the sole patient asset "relatively healthy".

2. Patient A2: The Psychiatric Evaluation dated 12/31/2016 stated as the sole patient asset "my family".

3. Patient A3: The Psychiatric Evaluation dated 12/31/2016 stated as the sole patient asset "my family".

4. Patient A4: The Psychiatric Evaluation dated 1/01/2016 stated as the sole patient asset "my family".

B. Treatment Plan goals not individualized and measurable:
See, B121 for details.

C. Treatment Plan modalities generic discipline tasks and not patient specific:
See, B122 for details.

Based on record review, document review and interview the Director of Nursing failed to:

I. Ensure that nursing interventions were individualized for four (4) of four (4) sample patients (A1, A2, A3 and A4). This deficiency resulted in a failure to provide a basis for purposeful, directed treatment and to plan revisions based on individual patient needs and assessments.

A. Record Review:

1. Patient A1 (Master Treatment Plan dated 1/3/16) had the following nursing interventions for the short term goals: "Be safe on the unit. Have a safety plan by 1/6/16. Attend daily groups [and] provide daily [treatment] goals. Demonstrate more euthymic mood [with] no thoughts of self-harm by the time of [discharge]."

Nursing Interventions

a. "Provide for general precautions."

b. "Encourage daily structure."

c. "Group attendance. Daily [treatment] goals."

d. "Assess [client's mood [and] cognition bid [twice daily] [and] prn [as needed]."


These interventions were not individualized and were general hospital functions.

2. Patient A2 (Master Treatment Plan dated 1/1/16) had the following nursing interventions for the short term goals: "Remain safe while in the [inpatient unit]. Make a no suicide contract [every] day until [discharge]. Remain safe while in the [inpatient unit] with the aid of [nursing] interventions [and] support."

Nursing Interventions

a. "Obtain a no self-harm contract [every] shift until [discharge]".

b. "Assist [client] in completing his safety plan by day 3."

c. "Encourage [client] to talk about his feelings and problems solve alternatives."

Social Work Interventions

a. "Complete psychosocial assessment within 72 hours of admission."

b. "Provide opportunity for daily group therapy."

c. "Assist with discharge planning."

These interventions were not individualized and were general hospital functions.

3. Patient A3 (Master Treatment Plan dated 1/1/16) had the following nursing interventions for the short term goals: "Complete safety contract by day 2. Contract for no self-harm [every] shift until [discharge]. Remain safe while in the [inpatient unit]."

Nursing Interventions:

a. "Obtain a no self-harm contract [every] shift until [discharge]."

b. "Assist [client] in completing safety contract [and] plan by day 2."

c. "Encourage [client] to talk about feelings and problem solve alternatives."

These interventions were not individualized and were general hospital functions.

4. Patient A4 (Master Treatment Plan dated 1/1/16) had the following nursing interventions for the short term goals: "Contract for no self-harm [every] shift until [discharge]. Remain safe on the [inpatient unit] throughout hospitalization. Complete safety plan by day 3."

Nursing Interventions:

a. "Assist [client] in completing safety plan by day 3."

b. "Obtain suicide contract [every] shift until [discharge]."

c. "Encourage [client] to talk about feelings and problem solve alternatives."


These interventions were not individualized and were general hospital functions.

B. Interview

On 1/5/16 at 2:05 PM the Director of Nursing, stated, "I can see that the interventions are things that we do for everyone."

II. Ensure that nursing staff were clinically and administratively supervised by a Registered Nurse.

A. Document Review

1. The Position Description for the Program Administrator (who was educated as a Licensed Mental Health Counselor) stated that this position "provides back up coverage to the Nursing Supervisor for utilization review and management of the nursing staff." In addition, the position description listed the Inpatient Nursing Supervisor as a "Supervisee."

2. The Position Description for the Inpatient Nursing Supervisor stated that the "Immediate Supervisor" for this position was the "Program Administrator" (the aforementioned Licensed Mental Health Counselor."

3. The Employee Performance Appraisal Report for the Inpatient Nursing Supervisor was signed by the Program Administrator as the "Evaluator" on 10/22/15. The Director of Nursing did not sign the document.

4. The Employee Performance Appraisal Report for a program (Nursing) assistant was signed by the Program Administrator as the "Evaluator" on 9/18/15.

B. Interviews

1. On 1/5/16 at 12:45 PM the Director of Nursing stated, "Yes, the Inpatient Program Director supervises Nursing in the absence of the Nursing Supervisor."

2. On 1/5/15 at 10:45 PM the Inpatient Nursing Supervisor stated, "Yes, the Program Administrator manages the nursing staff in my absence. She also completed some nursing evaluations in 2015 and she helps hire nurses."

Based on medical record review and staff interview it was determined that for 4 of 4 patients the Director of Social Work failed to monitor and take corrective action for the quality and appropriateness of social services. Without monitoring there is the potential for major gaps in social service provision.

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychosocial Assessment dated 1/04/2016 stated as the social functioning conclusion or formulation " Client will benefit from ongoing psychiatric care, including medication management, and psychotherapy to address ongoing depression, suicidal ideation, and the learning of new and effective coping skills " . No patient specific social service role was described.

2. Patient A2: The Psychosocial Assessment dated 1/02/2016 stated " He will benefit from psychiatric evaluation. He will benefit from continued psychoeducation concerning stress management and positive coping skills " . No patient specific social service role was described for discharge planning. This Psychosocial Assessment was done by an Activity therapist staff member.

3. Patient A3: The Psychosocial Assessment dated 1/02/2016 stated as the psychosocial formulation of the current baseline social functioning " He will benefit from further psychiatric evaluation and care. He will benefit from psychoeducation concerning stress management and utilize positive coping skills. He will benefit from psychotherapy " . This assessment was done by an Activity therapist staff member.

4. Patient A4: The Psychosocial Assessment dated 1/02/2016 stated " He will benefit from psychiatric evaluation. He will benefit from medically supervised detoxification. He will benefit from psychoeducation concerning ways in which to abstain from substances. He will benefit from psychotherapy to aid in maintaining sobriety " . This assessment was done by an Activity therapist staff member.

II. Staff Interview:

1. On 1/05/2016 at 10:55AM the Director of Social Work was interviewed. After reviewing the Psychosocial Assessments of Patients A1, A2, A3 and A4, she agreed -

(a) there was not present a psychosocial assessment of baseline functioning for any of the 4 patients.

(b) that for the Psychosocial Assessments done by Activity therapy staff, there was no evidence of monitoring by a Social Worker of conclusions and recommendations or a description of the role of the social service staff in treatment and discharge planning.

2. On 1/04/2016 at 2:15 PM the facility's Program Administrator told the surveyor "Not all of them (Psychosocial Assessments) are reviewed by a Social Worker".

3. On 1/05/2016 at 2:15 PM the Director of Social Work was interviewed. She was shown the treatment modalities found on the Treatment Plans of Patients A1, A2, A3 and A4. She agreed that the modalities as written were generic social work functions and not patient specific interventions. See, also B122 for details re. Treatment Plan modalities.

4. On 1/06/2016 at 11:25 AM the facility's C.E.O. was asked to provide the facility's job description for the staff member designated as the Director of Social Work at the entrance conference on 1/04/2016. He reported there does not exist a job description for this position. Therefore, it is not possible to state that the Director is failing to perform tasks designated by hospital policy.