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Based on record review and interview, the hospital failed to ensure each patient had an individualized comprehensive treatment plan that included activities based on an activity assessment of the patients' likes and dislikes for 5 (#1, #2, #3, #4 and #5) of 5 patient record reviewed for comprehensive treatment plans for a total sample of 5 patients.

Findings:

Review of the policy titled "Treatment Plans", Document Number PC-501, dated July 10, 2012 revealed in part: To identify, evaluate, and update care and services appropriate to the individual's specific needs in order to promote therapeutic progress and provide treatment direction. B. Initial Treatment Plan. 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. This initial treatment plan is utilized to implement immediate treatment objectives. a) Therapeutic efforts begin when the initial treatment plan is developed. b) Problems are added to the problem list as they occur.

Review of the hospital policy titled "Assessments of Patients", Document Number PC-104, dated July 10, 2012 revealed in part: To define the scope and time frames for patient assessments for each discipline involved in an individual patient's treatment. Activity assessment - AD/AT/CTRS - within 72 hours of admission.

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Patient #1
Record review on 01/09/19 revealed patient #1 was admitted on 01/06/19 at 7:00 p.m. with diagnosis of Major depressive disorder, recurrent episode, severe without mention of psychotic behavior. Further review of the Care Plan dated 01/07/19 revealed no activities were care planned for patient #1, and no activity assessment had been completed.

Patient #2
Record review on 01/09/19 revealed patient #2 was admitted on 01/05/19 at 5:30 a.m. with diagnosis of Drug induced psychotic disorder with hallucinations. Further review of the Care Plan dated 01/06/19 revealed no activities were care planned for patient #2, and no activity assessment had been completed.

Patient #3
Record review on 01/09/19 revealed patient #3 was admitted on 01/08/19 at 6:15 p.m. with diagnosis of Postpartum, mental disorders of mothers. Further review of the Care Plan dated 01/08/19 revealed no activities were care planned for patient #3, and no activity assessment had been completed.

Patient #4
Record review on 01/09/19 revealed patient #4 was admitted on 01/05/19 at 7:30 a.m. with diagnosis of Schizoaffective disorder. Further review of the Care Plan dated 01/07/19 revealed no activities were care planned for patient #4, and no activity assessment had been completed.

Patient #5
Record review on 01/09/19 revealed patient #5 was admitted on 12/31/18 at 3:55 p.m. with diagnosis of Dementia unspecified, without behavioral disturbance. Further review of the Care Plan dated 01/06/19 revealed no activities were care planned for patient #5, and no activity assessment had been completed.

In an interview on 01/09/19 at 2:10 p.m. with S2DON, she confirmed the patients had no Treatment Plans to include Activity Therapy. S2DON further stated that the activity assessments had not been done on patients because there was no Activity Therapy Director on staff providing those services in the hospital.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Staff Requirements for Psychiatric Hospital as evidenced by:

1) Failing to ensure the hospital provided a therapeutic activities program. (see findings in B-0156).

2) Failing to ensure the therapeutic activities program was appropriate to the needs and interests of the patients. (see findings in B-0157).

3) Failing to ensure the hospital employed a qualified therapist to provide comprehensive therapeutic activities consistent with each patient's active treatment program. (see findings in B-0158).

Based on record review and interviews, the hospital failed to provide a therapeutic activities program that addressed individual patient needs for 5 (#1, #2, #3, #4, and #5) of 5 sampled patients.

Findings:

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: The hospital provides inpatient psychiatric care for patients who are unable to benefit from a less intensive treatment. The hospital program provides the following vital components in the overall continuum of care: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Patient #1
Review of the Care Plan dated 01/07/19 revealed no goals and/or interventions for activities were care planned for patient #1.

Interview on 01/09/19 at 1:40 p.m. with patient #1 revealed that she was admitted to the hospital 4 days ago. Patient #1 confirmed that no one during the admission process to the hospital had asked her what kind of activities that she liked to do. Patient #1 told surveyor that she liked to do word puzzles. Patient #1further stated that there were coloring books and puzzles in the activity room but no one offered her any of those to do, she did not like to do puzzles or color.

Patient #2
Review of the Care Plan dated 01/06/19 revealed no goals and/or interventions for activities were care planned for patient #2.

Patient #3
Review of the Care Plan dated 01/08/19 revealed no goals and/or interventions for activities were care planned for patient #3.

Interview on 01/09/19 at 1:50 p.m. with patient #3 revealed she had only been admitted to the hospital for one day. Patient #3 stated that no one had asked her during her admission process anything about what kind of activities she likes to do. Patient #3 further stated that since she has been here no one has offered her anything to do. Patient #3 stated that there were puzzles and coloring books in the Activity/TV room but none of the staff had encouraged her to use them.

Patient #4
Review of the Care Plan dated 01/07/19 revealed no goals and/or interventions for activities were care planned for patient #4.

Patient #5
Review of the Care Plan dated 01/06/19 revealed no goals and/or interventions for activities were care planned for patient #5.

In an interview on 01/09/19 at 12:50 p.m. with S2DON, she confirmed that there was no one on staff right now functioning as the Activity Therapist. S2DON further stated there were no structured activity sessions being provided to the patients, and the activity assessments were not being completed.

Based on record review, and patient and staff interview, the hospital failed to ensure the activity program was appropriate to the needs and interests of patients as evidenced by failing to identify and provide individualized therapeutic activities directed toward restoring and maintaining optimal levels of functioning for 5 (#1, #2, ##, #$, and #5) of 5 sampled patients.

Findings:

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Review of the hospital policy titled "Assessments of Patients", Document Number PC-104, dated July 10, 2012 revealed in part: To define the scope and time frames for patient assessments for each discipline involved in an individual patient's treatment. Activity assessment - AD/AT/CTRS - within 72 hours of admission.

Patient #1
Record review on 01/09/19 revealed patient #1 was admitted on 01/06/19 at 7:00 p.m. with diagnosis of Major depressive disorder, recurrent episode, severe without mention of psychotic behavior. Further review of the Care Plan dated 01/07/19 revealed no activities were care planned for patient #1, and no activity assessment had been completed.

Interview on 01/09/19 at 1:40 p.m. with patient #1 revealed that she was admitted to the hospital 4 days ago. Patient #1 confirmed that no one during the admission process to the hospital had asked her what kind of activities that she liked to do. Patient #1 told surveyor that she liked to do word puzzles. Patient #1further stated that there were coloring books and puzzles in the activity room but no one offered her any of those to do, she did not like to do puzzles or color.

Patient #2
Record review on 01/09/19 revealed patient #2 was admitted on 01/05/19 at 5:30 a.m. with diagnosis of Drug induced psychotic disorder with hallucinations. Further review of the Care Plan dated 01/06/19 revealed no activities were care planned for patient #2, and no activity assessment had been completed.

Patient #3
Record review on 01/09/19 revealed patient #3 was admitted on 01/08/19 at 6:15 p.m. with diagnosis of Postpartum, mental disorders of mothers. Further review of the Care Plan dated 01/08/19 revealed no activities were care planned for patient #3, and no activity assessment had been completed.

Interview on 01/09/19 at 1:50 p.m. with patient #3 revealed she had only been admitted to the hospital for one day. Patient #3 stated that no one had asked her during her admission process anything about what kind of activities she likes to do. Patient #3 further stated that since she has been here no one has offered her anything to do. Patient #3 stated that there were puzzles and coloring books in the Activity/TV room but none of the staff had encouraged her to use them.

Patient #4
Record review on 01/09/19 revealed patient #4 was admitted on 01/05/19 at 7:30 a.m. with diagnosis of Schizoaffective disorder. Further review of the Care Plan dated 01/07/19 revealed no activities were care planned for patient #4, and no activity assessment had been completed.

Patient #5
Record review on 01/09/19 revealed patient #5 was admitted on 12/31/18 at 3:55 p.m. with diagnosis of Dementia unspecified, without behavioral disturbance. Further review of the Care Plan dated 01/06/19 revealed no activities were care planned for patient #5, and no activity assessment had been completed.

In an interview on 01/09/19 at 2:10 p.m. with S2DON, she confirmed the patients had no Treatment Plans to include Activity Therapy. S2DON further stated that the activity assessments had not been done on patients because there was no Activity Therapy Director on staff providing those services in the hospital.

Based on record reviews and interview, the hospital failed to ensure there was an adequate number of qualified therapists, support personnel to provide comprehensive therapeutic activities consistent with each patients' active treatment plan as evidenced by the hospital failing to have on staff a qualified Therapeutic Activities Therapist.

Findings:

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Review of the medical records of Patients #1, #2, #3, #4, and #5 revealed no documented evidence that activity therapy groups were conducted.

Review of the Daily Patient Schedule given to surveyor by S4CSW revealed structured activities were scheduled for 10:00 a.m., 2:30 p.m. - 3:15 p.m., and 4:00 p.m.

In an interview on 01/09/19 at 10:30 a.m. with S4CSW, she confirmed that she did not do any structured activities with the patients, she only does group therapy. S4CSW further stated that there was no current Activities Director.

In an interview on 01/09/19 at 10:45 a.m. with S5LPC, she confirmed that she was just PRN and only worked on Wednesday. S5LPC stated that she only does group psychosocial therapy with the patients and does not do any type of activity therapy with the patients. S5LPC further stated that she had just started in November one day a week, but wasn't aware of a current Therapeutic Activities Therapist working with the patients.

In an interview on 01/09/19 at 12:50 p.m. with S2DON, she confirmed that there was no one on staff right now functioning as the Activity Therapist. S2DON further stated there was no structured activity sessions being provided to the patients as of right now.