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Based upon observation record review, staff interviews and the deficiencies documented in this report there is a systematic failure by the facility to maintain medical records that depict the patients care, treatment and actual experiences in the facility. The deficient practices are pervasive in that 8 of 8 sample records reviewed lacked documentation for one or more of the following:

The facility failed to:

I. Provide and document a psychiatric evaluation within 60 hours of admission for 1of 8 active sample patients (E10). Failure to complete timely psychiatric evaluations compromises the treatment team's ability to formulate necessary goals and interventions for treatment. (Refer to B111)

II. Provide and document psychiatric evaluations that included an assessment of intellectual functioning for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11), an estimate of memory for 7 of 8 active sample patients (C3, C11, D7, D8, D14, E10 and E 11) and an estimate of orientation for 1 of 8 active sample patients (C3). This deficient practice compromises the database from which diagnoses are determined and from which changes in response to treatment can be made. (Refer to B116)

III. Provide Master Treatment Plans for 6 of 8 active sample patients (Patients C3, C11, D6, D7, D8 and D14) that included individualized short-term and long range goals. The short-term and long range goals were identical and/or very similar generic goals for the patients and were checked off on pre-printed treatment plan forms. This deficiency results in treatment plans that fail to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

IV. Include individualized activity therapy/occupational therapy/recreational therapy (AT/OT/RT) interventions on the Master Treatment Plans of 7 of 8 active sample patients (C3, D6, D7, D8, D14, E10 and E11). The area on the Master Treatment Plans for these services was either left blank or only listed generic discipline tasks instead of individualized interventions. Three of the MTPs (D6, D7 and D14) also listed generic physician and/or nursing tasks with no specified frequency of delivery of the interventions. These deficiencies result in lack of guidance for staff in delivering goal directed individualized interventions for patients. (Refer to B122)

V. Identify the specific team members who were responsible for treatment interventions listed on the Master Treatment Plans of 3 of 8 sample patients (C11, D7 and D8). This failure results in lack of staff accountability and continuity of care, potentially delaying patients' recovery. (Refer to B123)

VI. Ensure that individualized active treatment modalities were offered on a regularly scheduled basis on units C, D and E for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11). The expectation was that all patients on the units were to attend the groups/activities listed on the activity schedules on the units. Although multiple treatment modalities were identified on the unit activity schedules, the staff did not adhere to the schedules and often were not aware of the scheduled group or activity. This frequently resulted in no group or therapeutic activity for the patients to attend. Failure to provide scheduled treatment results in patients being hospitalized without all interventions being provided, potentially delaying their improvement. (Refer to B125)

Based on record review, policy review and interview, the facility failed to provide a psychiatric evaluation for 1 of 8 active sample patients (E10) within 60 hours of admission. Failure to complete timely psychiatric evaluations hampers the treatment team's ability to develop an effective treatment plan.

Findings include:

A. Record Review

Patient E10 was admitted on 05/27/2011. Review of the medical record of the patient revealed that the psychiatric evaluation was not completed until 120 hours after admission.

B. Policy Review

According to facility policy, the psychiatric evaluation is required to be completed within 24 hours of admission.

C. Interview

In an interview on 05/07/2011 at 11:30AM, the Medical Director acknowledged that the psychiatric evaluation for patient E10 was not done in a timely manner and stated "It was a human error."

Based on record review and interview, the facility failed to ensure that psychiatric evaluations included an estimate of intellectual functioning for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11), an estimate of memory functioning for 7 of 8 active sample patients (C3, C11, D7, D8, D14, E10 and E11), and an estimate of orientation for 1 of 8 active sample patients (C3). Failure to document specific test results compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examinations to assess patients' response to treatment interventions.

Findings include:

A. Record Review

1. Patient C3 was admitted on 06/05/2011. The psychiatric evaluation done on 06/06/2011 did not document an estimate of orientation, memory functioning, or intellectual functioning.

2. Patient C11 was admitted on 06/02/2011. The psychiatric evaluation done on 06/03/2011 did not document an estimate of memory functioning or intellectual functioning.

3. Patient D6 was admitted on 06/03/2011. The psychiatric evaluation done on 06/04/2011 did not document an estimate of intellectual functioning.

4. Patient D7 was admitted on 06/03/2011. The psychiatric evaluation done on 06/03/2011 did not document an estimate of memory functioning or intellectual functioning.

5. Patient D8 was admitted on 06/04/2011. The psychiatric evaluation done on 06/05/2011 did not document an estimate of memory functioning and intellectual functioning.

6. Patient D14 was admitted on 05/29/2011. The psychiatric evaluation done on 05/30/2011 did not document an estimate of memory functioning and intellectual functioning.

7. Patient E10 was admitted on 05/27/2011. The psychiatric evaluation done on 06/01/2011 did not document an estimate of memory functioning and intellectual functioning.

8. Patient E11 was admitted on 05/17/2011. The psychiatric evaluation done on 05/18/2011 did not document an estimate of memory functioning and intellectual functioning.

B. Interview

In an interview on 06/07/2011 at 2:00PM, the Medical Director agreed that all psychiatric evaluations did not document an estimate of orientation, memory functioning and intellectual functioning. The Medical Director stated "I have realized we need to improve on these areas."

Based on record review and interviews, it was determined that the facility failed to develop individualized short-term and long range goals for 6 of 8 active sample patients (C3, C11, D6, D7, D8 and D14). The listed short-term and long range goals, checked off from preprinted treatment plan forms, were identical or very similar for the patients. Lack of individualized goals on patients MTPs hampers staff's ability to evaluate the effectiveness of interventions designed to help the patient achieve specific treatment outcomes.

Findings include:

A. Record Review

1 .Patient C3 was admitted on 6/5/11. The treatment plan dated 6/6/11 included "Mania and substance abuse" as identified problems. For the identified problem of "substance abuse," the long range goals were "verbalize understanding of need for abstinence in order to maintain recovery post detoxification/treatment", "complete withdrawal period without complications" and "be able to at least 3 sources in the community to assist in maintenance of recovery." For the identified problem of "substance abuse", the short term goals were "(Patient's name) will notify staff as soon as symptoms of withdrawal are evident", "(patient's name) will maintain at least 24 hours free of symptoms of withdrawal for 3 consecutive days by discharge", "(patient's name) will respond to redirection by staff to attend at least 80% of groups and activities to effectively divert attention to continuing recovery when cravings arise" and "(Patient's name) will be able to verbalize at least 4 triggers for substance use and 3 cues to utilize tools for recovery at least 1 time."

2. Patient C11 was admitted on 6/2/11. The treatment plan dated 6/3/11 included "delusional thoughts" and "substance abuse" as identified problems. For the identified problem "substance abuse," the long range goals were "verbalize understanding of need for abstinence in order to maintain recovery post detoxification/treatment", "complete withdrawal period without complications" and "be able to at least 3 sources in the community to assist in maintenance of recovery". For the identified problem "substance abuse," the short term goals were "(Patient's name) will notify staff as soon as symptoms of withdrawal are evident", "(patient's name) will maintain at least 24 hours free of symptoms of withdrawal for 3 consecutive days by discharge" and "(patient's name) will respond to redirection by staff to attend at least 80% of groups and activities to effectively divert attention to continuing recovery when cravings arise."

3. Patient D6 was admitted on 6/3/11. The treatment plan dated 6/6/11 included "depression" and "substance abuse" as identified problems. For the identified problem "substance abuse," the long range goals were "verbalize understanding of need for abstinence in order to maintain recovery post detoxification/treatment", "complete withdrawal period without complications" and "be able to at least 3 sources in the community to assist in maintenance of recovery". For the identified problem "substance abuse," the short term goals were "(Patient's name) will notify staff as soon as symptoms of withdrawal are evident", "(patient's name) will maintain at least 24 hours free of symptoms of withdrawal for 3 consecutive days by discharge", "(patient's name) will respond to redirection by staff to attend at least 80% of groups and activities to effectively divert attention to continuing recovery when cravings arise" and "(Patient's name) will be able to verbalize at least 4 triggers for substance use and 3 cues to utilize tools for recovery at least 1 time."
4. Patient D7 was admitted on 6/3/11. The treatment plan dated 6/6/11 included "suicidal thoughts" and "depressive symptoms" as identified problems. For the identified problem of "suicidal thoughts," the long range goals were "not demonstrate or verbalize active suicide plan for a period of 3 days", "have reduced thoughts of self harm to fewer than 0 per day", "verbalize an ability to recognize, accept and cope with symptoms of depression", "verbalize knowledge of depression and at least 3 ways to access help if depressive symptoms should recur" and "verbalize 3 realistic plan(s) for the future which could help to reduce the risk of relapse incorporating losses and changes by the time of discharge." For the identified problem "suicidal thoughts," the short-term goals were "(Patient's name) will alert staff if having active suicidal thoughts/ideation and verbalize 2 alternative way(s) of coping", "(Patient's name) will make no attempt to harm self for 3 consecutive days", "(Patient's name) will participate in 2 socialization opportunities per day for 2 consecutive days" and "(patient's name) will accept consequences for using maladaptive behavior."
5. Patient D8 was admitted on 6/4/11. The treatment plan dated 6/6/11 included "substance abuse" and "depression" as identified problems. For the identified problem "substance abuse," the long range goals were "verbalize understanding of need for abstinence in order to maintain recovery post detox/treatment", "complete withdrawal period without complications", and "be able to at least 3 sources in the community to assist in maintenance of recovery". For the identified problem "substance abuse," the short term goals were "(Patient's name) will notify staff as soon as symptoms of withdrawal are evident", "(patient's name) will maintain at least 24 hours free of symptoms of withdrawal for 3 consecutive days by discharge" and "(patient's name) will respond to redirection by staff to attend at least 80% of groups and activities to effectively divert attention to continuing recovery when cravings arise."
6. Patient D14 was admitted on 5/29/11. The treatment plan dated 5/31/11 included "suicidal thoughts" and "depression" as identified problems. For the identified problem "suicidal thoughts," the long range goals were "not demonstrate or verbalize active suicide plan for a period of 3 days", "have reduced thoughts of self harm to fewer than 0 per day", "verbalize an ability to recognize, accept and cope with symptoms of depression", "verbalize knowledge of depression", "at least 3 ways to access help if depressive symptoms should recur" and "verbalize 3 realistic plan(s) for the future which could help to reduce the risk of relapse incorporating losses and changes by the time of discharge." For the identified problem "suicidal thoughts," the short-term goals were "(Patient's name) will alert staff if having active suicidal thoughts/ideation and verbalize 2 alternative way(s) of coping", "(Patient's name) will make no attempt to harm self for 3 consecutive days", "(Patient's name) will participate in 2 socialization opportunities per day for 2 consecutive days" and "(patient's name) will accept consequences for using maladaptive behavior." For the identified problem "depression," no short-term and long range goals were on the treatment plan.

B. Interviews

In an interview on 6/7/11 at 4PM, The Director of Clinical Services agreed that the short term and long range goals were not individualized for patients but were generic in nature. The Director of Clinical Services also stated "We can definitely improve."

Based on record review and interview, the facility failed to include individualized activity therapy/occupational therapy/recreational therapy (AT/OT/RT) interventions on the Master Treatment Plans of 7 of 8 active sample patients (C3, D6, D7, D8, D14, E10 and E11). The area on the Master Treatment Plans for these services was either left blank or listed generic discipline tasks instead of individualized interventions. Three of the MTPs (D6, D7 and D14) also listed generic physician and/or nursing tasks with no specified frequency of delivery of the interventions. These deficiencies result in lack of guidance for staff in delivering goal directed individualized interventions for patients.

Findings include:

A .Record Review

1. Patient C3 (admitted 6/5/11). On the Master Treatment Plan of 6/6/11, for the problem "Mania and Substance Abuse," the section titled AT/OT/RT intervention was left blank.

2. Patient D6 (admitted 6/3/11). On the Master Treatment Plan of 6/6/11, the section titled AT/OT/RT intervention was left blank for the problem "substance abuse withdrawal." For the problem "depression," the pre-printed interventions for AT/OT/RT Section were generic and not individualized. One of the interventions for nurses, "provide education regarding increasing motivation and awareness of physical coping skills...," did not specify the frequency of the intervention.

3. Patient D7 (admitted 6/3/11). The Master Treatment Plan of 6/6/11 included "suicidal thoughts/plan/attempt" and "depressive symptoms" as identified problems. There were no activity therapy interventions on the treatment plan. For the listed problem "suicidal thoughts/plan/attempt," the physician, nursing and therapist interventions were not individualized for the patient but were generic discipline tasks with no specified frequencies. The pre-printed Physician intervention was "assess and adjust medications" with no specified number of times/week on the blank line on the form. A nursing pre-printed intervention, "perform environmental rounds/safety checks per precaution level" also had no specified frequency. A pre-printed therapist intervention, "encourage patient to identify thoughts related to self-harm and educate on techniques for control of suicidal thoughts in 1:1 and group settings" did not have any frequency.

4. Patient D8 (admitted 6/4/11). The Master Treatment Plan of 6/6/11 included "substance abuse" and "depression" as identified problems. There were no activity therapy interventions on the plan for the problem "depression."

5. Patient D14 (admitted 5/29/11). The Master Treatment Plan of 5/31/11 included "suicidal thoughts/plan/attempt" and "depression" as identified problems. There were no activity therapy interventions on the treatment plan. For the problem "suicidal thoughts/plan/attempt," the physician, nursing and therapist interventions were not individualized for the patient, but were generic discipline tasks with no specified frequencies. The pre-printed physician intervention, "assess and adjust medications" had no specified number of times/week. The preprinted nursing intervention, "perform environmental rounds/safety checks per precaution level" also specified no frequencies. A pre-printed therapist intervention, "encourage patient to identify thoughts related to self-harm and educate on techniques for control of suicidal thoughts in 1:1 and group settings" had no specified frequencies.

6. Patient E10 (admitted 5/27/11). On the Master Treatment Plan of 5/30/11, for the problem "psychotic symptoms/delusional thoughts," the section titled AT/OT/RT interventions was left blank. This section was also left blank for the problem "substance abuse withdrawal."

7. Patient E11, admitted 5/17/11. On the Master Treatment Plan of 5/18/11, for the problem "disruptive behavior," the section titled AT/OT/RT interventions was left blank.

B. Interview

1. In an interview on 06/07/2011 at 2PM, the Medical Director agreed that the treatment plans were not individualized and stated, "We need to improve."

2. In an interview on 06/07/2011 at 4PM, the Director of Clinical Services agreed that some of the identified patient's problems were not addressed with individualized interventions. The Director of Clinical Services also stated. "We can definitely improve."

Based on record review and policy review, the facility failed to identify the specific team members who were responsible for treatment interventions listed on the Master Treatment Plans of 3 of 8 sample patients (C11, D7 and D8). This failure results in lack of staff accountability and continuity of care, potentially delaying patients' recovery.

Findings include:

A. Record Review

1. Patient C11 (admitted 6/2/11). The Master Treatment Plan dated 6/3/11 included "delusional thoughts" and "substance abuse" as identified problems. For each of these identified problems, the name of the staff responsible for providing activity interventions was only listed as "MHA (Mental Health Assistant)."

2. Patient D7 (admitted 6/3/11). The Master Treatment Plan of 6/6/11 only stated "MHA" as the staff responsible for providing activity therapy interventions for the problem "depression." No names of responsible persons were listed.

3. Patient D8 (admitted 6/4/11). The Master Treatment Plan of 6/6/11 only identified "MHA" as the staff responsible for providing activity therapy interventions for the problem "substance abuse."

B. Policy Review

The facility policy, TX 1.1c, titled "Writing Treatment Plans," dated 3/99, states on page 2, under the section "Responsible staff": "this lists which specific team member will facilitate each particular intervention listed in the previous [intervention] column ...2. These must be listed by name as well as discipline with only one individual per intervention."

Based on observations, record review, document review and interview, the facility failed to ensure that individualized active treatment modalities were offered on a regularly scheduled basis for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11). The expectation was that all patients were to attend the groups/activities listed on the activity schedules on their units. Although multiple treatment modalities were identified on the unit activity schedules, the staff did not adhere to the schedules and often were not aware of the scheduled group or activity. This frequently resulted in no group or therapeutic activity for the patients to attend. In addition, there was lack of documentation that the patients received alternative interventions. Failure to provide scheduled treatment results in patients being hospitalized without all interventions being provided, potentially delaying their improvement.

Findings include:

A. Observations

1. During an observation on 6/6/11 at 11:30AM on the dual diagnosis unit (Unit D), the posted program schedule showed that a group psychotherapy session was to be occurring. The surveyor asked the charge nurse, RN1, where the group was being held and who was leading this group. RN1 was unaware of the group scheduled and was not aware of who was to be leading the group. She paged one therapist to find out details of the group and was directed to page a second therapist. She received no return call with the second page. At 12 PM, the group had not yet started.

2. During an observation on 6/6/11 at 2:30PM on the gero-psychiatric unit (Unit E), a music listening activity was scheduled on the posted scheduled to be conducted by the MHA. When the surveyor entered the unit, there was no structured activity being conducted. The patients were sitting in the day room with staff, eating snacks. MHA1 stated she was not aware of the activity that was scheduled.

3. During an observation on 6/7/11 at 4:15PM on the gero-psychiatric unit (Unit E), patient E11 was pacing in the corridor with staff in attendance. During this time, the posted unit schedule showed that an activity therapy session was scheduled to occur. When the surveyor asked MHA2, what activities were planned for this patient this evening, he stated, "We will probably walk all night; she doesn't attend anything."

B. Record Review

1 .Patient C3 was admitted 6/5/11 with a diagnosis "Bipolar Affective Disorder Manic with Psychosis; Cocaine Abuse." A psycho-educational group therapy documentation note dated 6/6/11 stated that the patient did not attend two groups held on the unit (affective education and coping skills). According to the program schedule for this date, 7 other groups/structured activities were scheduled to occur. There was no documentation that the scheduled groups occurred or that the patient received alternative activities.

2. Patient C11 was admitted 6/2/11 with a diagnosis "Schizophrenia, paranoid type; drug induced psychosis." A psycho-educational group therapy documentation note dated 6/3/11 showed that the patient attended two of three groups held on the unit (self-esteem and group psychotherapy). A psycho-educational group therapy documentation note stated that the patient "did not attend" the 1:00-2:15PM skills group. According to the program schedule for this date, ten groups/activities were scheduled to take place on the unit. There was no documentation that 7 of the groups were offered as scheduled. For 6/5/11, there only was documentation that the patient attended one of 10 scheduled groups. On 6/6/11, 7 groups/activities were on the schedule. There was no documentation that the scheduled groups were completed or that the patient received alternative interventions.

3. Patient D6 was admitted 6/3/11 with a diagnosis of "Alcohol Dependence/Depression NOS and Chronic Pain." On 6/4/11, 9 groups were scheduled to occur on the unit, but only six groups actually occurred as scheduled. On 6/5/11, 9 groups were scheduled to occur on the unit, but only six groups actually occurred as scheduled. On 6/6/11, 10 groups/activities were scheduled, but only 4 groups actually occurred. There was no documentation that the patient received alternative interventions.

4. Patient D7 was admitted 6/3/11 with a diagnosis "Major Depressive Disorder, recurrent, severe without psychosis; rule out post-partum depression; poly substance abuse in partial remission." According to the unit schedule, on 6/3/11, 10 groups/activities were to occur on the unit; only six groups were held. On 6/4/11, 9 groups were scheduled but only four were held. On 6/5/11, 9 groups/activities were scheduled but only 5 were held. On 6/6/11, 10 groups/activities were scheduled to occur but only 4 were held. There was no documentation that alternative interventions were used to provide active treatment for the patient.

5. Patient D8 was admitted 6/4/11 with "Alcohol Dependence; rule out major depression." On 6/5/11, 9 groups/activities were on the unit schedule, but only 6 groups were actually held. On 6/6/11, 10 groups/activities were scheduled, but only 6 occurred. There was no evidence that alternative interventions were provided to the patient.

6. Patient D14 was admitted 5/29/11 with "Major Depressive Disorder, recurrent, severe; drug and alcohol abuse." On 6/3/11, 10 groups/activities were on the unit schedule but only 4 groups were actually held. On 6/4/11, 9 groups/activities were scheduled but only 5 groups were held. On 6/5/11, 9 groups/activities were scheduled but only 6 groups were held. On 6/6/11, 10 groups/activities were scheduled but only 5 of these were held. There was no documentation that alternative interventions were used to provide active treatment for the patient.

7. Patient E10 was admitted 5/27/11 with "Psychotic Disorder NOS; Poly-substance Abuse." On 6/4/11, 7 groups/activities were on the unit schedule, but only 3 of the groups/activities were held. On 6/5/11, 7 groups/activities were scheduled but only 3 of these were held. On 6/6/11, 7 groups/activities were scheduled but only 2 occurred. There was no documentation that alternative interventions were used to provide active treatment for the patient.

8. Patient E11 was admitted 5/17/11 with "Alzheimer Dementia with Behavioral Disturbance and Psychosis." A psycho-educational group therapy note dated 6/5/11 showed that the patient was excused from two activities -- a structured recreation group from 10:20AM-11:00AM and a "community meeting" from 11:25AM to 12:00PM because she was " confused and anxious." No other group documentation was on the record for this date. According to the posted schedule, 4 additional groups/structured activities were scheduled to occur. The psycho-educational group therapy note dated 6/6/11 for the 10:00AM-10:50AM community meeting noted that the patient was "excused due to limitations of understanding." No other group documentation was on the record for this date. According to the posted schedule, 6 additional groups/scheduled activities were scheduled to occur but were not held. There was no evidence that alternative interventions were being used to provide active treatment for the patient.

C. Interviews

1. During an interview on the gero-psychiatric unit on 6/6/11 at 11:10AM, MHA1 stated that she combined the 9:45AM activity group with the 10:30AM community meeting into one group that she had run from 10:00AM until 10:50AM because "we had a call-off; the activity therapist called off."

2. During an interview on 6/7/11 at 1:00PM, the Director of Clinical Services, who has responsibility for the activity program, reported "there is only one activity therapist, and she had called off both Monday and Tuesday and staff were scrambling around to make groups happen, but unfortunately not all occurred." She further stated that "most of the activities are done by the MHA's that report to nursing." Additionally, she reported "There is no quality monitoring done on the activity program that identifies whether the schedule is being maintained and meets the needs of the patients."

3. During an interview on 6/7/11 at 2:15PM, the Director of Nursing (DON) verified that the posted schedules on the units are the schedules that are to be followed for groups and activities. She further verified that the copies of the schedules given to the surveyors on the first day of the survey by the Director of Performance Improvement/Risk Management/Health Information Services are the current schedules. The DON reviewed the psycho-educational group therapy documentation notes for patients C11, D6 and E10 and verified that the groups scheduled did not occur.

4. In an interview on 6/7/11 at 4:30PM, patient D14 stated "After 5 PM there are no activities scheduled except for AA and NA meetings sometimes. Usually we have some free time after 5PM...get ready for dinner and then go to sleep."

Based on interviews and record review, the facility failed to provide adequate clinical leadership in medical, nursing and activity therapy to assure adequate monitoring and evaluation of care for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11). There was a lack of monitoring of inpatient psychiatric care by the Medical Director (Refer to B144); failure of the Director of Nursing to provide adequate organization of the inpatient units to ensure that treatment activities were carried out (Refer to B148), and inadequate monitoring by the Director of Clinical Services to ensure adequate AT staffing and completion of AT assessments and treatment planning and programming. (Refer to B157 and B158).

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and ensure quality psychiatric care for patients at the facility. Specifically, the Medical Director failed to assure that:
I. Physicians performed and documented psychiatric evaluations in a timely manner for 1 of 8 sample patients (E10). As a result, the treatment team did not have available the current baseline psychiatric assessment data to be used in establishing goals and interventions for the patient. (Refer to B111)
II. Physicians performed and documented an estimate of intellectual functioning on the psychiatric evaluations of 8 of 8 active sample psychiatric evaluations (C3, C11, D6, D7, D8, D14, E10 and E11), an estimate of memory functioning for 7 of 8 active sample patients (C3, C11, D7, D8, D14, E10 and E11), and an estimate of orientation for 1 of 8 active sample patients (C3). Failure to perform these tests and document the results compromises the identification of pathology which may be pertinent to the current mental illness and compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. Assure the development of individualized Master Treatment Plans that included short-term and long range goals for 6 of 8 active sample patients (C3, C11, D6, D7, D8 and D14). The listed short-term and long range goals, checked off from preprinted treatment plan forms, were identical or very similar for the patients. Lack of individualized goals on patients' MTPs hampers staff ' s ability to evaluate the effectiveness of interventions designed to help the patient achieve specific treatment outcomes. (Refer to B121)

IV. Assure that individualized interventions were included on the Master Treatment Plans of 7 of 8 active sample patients (C3, D6, D7, D8, D14, E10 and E11). The area on the Master Treatment Plans for AT/OT/RT interventions was either left blank or only listed generic discipline tasks instead of individualized interventions. Three of the MTPs (D6, D7 and D14) also listed generic physician and nursing tasks with no specified frequency of delivery of the interventions. These deficiencies result in lack of guidance for staff in delivering goal directed individualized interventions for patients. (Refer to B122)

V. Assure that the names of specific team members who were responsible for treatment interventions listed on the Master Treatment Plans of 3 of 8 sample patients (C11, D7 and D8) were specified. This failure results in lack of staff accountability and continuity of care, potentially delaying patients' recovery. (Refer to B123)

VI. Assure that individualized active treatment was provided for 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11).The expectation was that all patients were to attend the groups/activities listed on the posted activity schedules on their units. Although multiple treatment modalities were identified on the unit program schedules, the staff did not adhere to the schedules and often were not aware of the scheduled group or activity. This frequently resulted in no group or therapeutic activity for the patients to attend. In addition, there was lack of documentation that the patients received alternative interventions. Failure to provide scheduled treatment results in patients being hospitalized without all interventions being provided, potentially delaying their improvement. (Refer to B125)

Based on record review, observations and interviews, it was determined that the Director of Nursing failed to adequately monitor and assure the quality of nursing care provided to patients at the facility. Lack of organization and structure in the therapeutic environment, as directed and supervised by nursing personnel, contributed to patients not receiving all treatment planning and assigned active treatment. Specifically the Director of Nursing failed to:

I. Ensure that 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11) received all assigned treatment. The expectation was that all patients were to attend the groups/activities listed on the activity schedules on their units. Although multiple treatment modalities were identified on the unit program schedules, the nursing staff did not adhere to the schedules and often were not aware of the scheduled group or activity. This frequently resulted in no group or therapeutic activity for the patients to attend. In addition, there was lack of documentation that the patients received alternative interventions. Failure to provide scheduled treatment results in patients being hospitalized without all interventions being provided, potentially delaying their improvement. (Refer to B125)

II. Assure that Master Treatment Plans for 2 of 8 active sample patients (D7 and D14) included nursing interventions that were individualized for the patients and noted how often the interventions would occur. This failure results in lack of guidance to staff in delivering individualized care to patients.

A. Record Review

1. Patient D7 was admitted on 6/3/11. The Master Treatment Plan of 6/6/11 included "suicidal thoughts" and "depressive symptoms" as identified problems. For the problem "suicidal thoughts," he checked off nursing intervention was a preprinted generic nursing task without any identified frequencies. The pre-printed nursing intervention was "perform environmental rounds/safety checks per precaution level." The frequency of the intervention was not specified, and the line provided to individualize the intervention for the patient was left blank.

2. Patient D14 was admitted 5/29/11. The Master Treatment Plan of 5/31/11 included "suicidal thoughts" and "depression" as identified problems. For the problem "suicidal thoughts," the checked off nursing intervention was a preprinted generic nursing task without any identified frequencies. The pre-printed nursing intervention was "perform environmental rounds/safety checks per precaution level." The frequency of the intervention was not specified, and the line provided to individualize the intervention for the patient was left blank.

B. Interviews

In an interview on 6/7/11 at 2:15PM, the DON acknowledged that the treatment plans of patients D7 and D14 did not have individualized nursing interventions, but had "the identical interventions" recorded.

Based on record review, policy review and interview, the facility failed to provide a systematic approach for identifying and meeting the individual activity therapy (AT) needs of 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11). There were no AT assessments in any of the patients medical records, and therapeutic and/or leisure related AT interventions were lacking or inadequate. The lack of structured activities therapy programming has the potential to result in patients not meeting treatment goals, such as the need for developing new adaptive skills for discharge.

Findings include:

A. Record Review

1. A review of the sample patients' medical records (admission dates in parentheses) revealed that there were no assessments completed by activity therapy personnel to determine what therapeutic/leisure activities were required to assist the patients to meet their individual treatment goals. The reviewed records were as follows: C3 (6/5/11), C11 (6/2/11), D6 (6/3/11), D7 (6/3/11), D8 (6/4/11), D14 (5/29/11), E10 (5/27/11) and E11 (5/17/11).

2. Patient C3 (admitted 6/5/11). On the Master Treatment Plan of 6/6/11. for the problem "Mania and Substance Abuse, the section titled AT/OT/RT intervention was left blank.

3. Patient C11 (admitted 6/2/11). The Master Treatment Plan of 6/3/11 had no activity therapist signature on the section titled "treatment team signatures." The section for AT/OT/RT interventions was completed for the problems "psychotic thoughts" and "substance abuse withdrawal," but the discipline identified to carry out the activity interventions was "MHA," a nursing staff member, not AT staff.

4. Patient D6 (admitted 6/3/11). On the Master Treatment Plan of 6/4/11, the section titled AT/OT/RT intervention was left blank for the problem "substance abuse withdrawal." For the problem "depression," the listed interventions for AT/OT/RT were preprinted generic tasks rather than individualized interventions.

5. Patient D7 (admitted 6/3/11). The Master Treatment Plan of 6/6/11 included "suicidal thoughts" and "depressive symptoms" as identified problems. There were no listed activity therapy interventions for the problem "suicidal thoughts." For the problem, "depressive symptoms," only "MHA" (Mental Health Assistant) was listed for providing the activity interventions.

6. Patient D8 (admitted 6/4/11). The Master Treatment Plan of 6/6/11 included "substance abuse" and "depression" as identified problems. There were no activity therapy interventions on the plan for the problem "depression."

7. Patient D14 (admitted 5/29/11). The Master Treatment Plan of 5/31/11 included "suicidal thoughts/plan/attempt" and "depression" as identified problems. There were no activity therapy interventions on the treatment plan.

8. Patient E10 (admitted 5/27/11). On the Master Treatment Plan of 5/30/11, for the problem "psychotic symptoms/delusional thoughts," the section titled AT/OT/RT interventions was left blank. This section was also left blank for the problem " substance abuse withdrawal."

9. Patient E11 (admitted 5/17/11). On the Master Treatment Plan of 5/18/11, for the problem "disruptive behavior," the section titled AT/OT/RT interventions was left blank.

B. Policy Review

The facility policy, "IM4.1" titled "Timeliness of Patient Assessment," revised 6/07 and provided to the surveyors by the Director of Performance Improvement/Risk Management/Health Information Services on 6/6/11, had no requirement listed for discipline specific assessments by activity therapy staff.

C. Interview

1. In an interview on 6/7/11 at 1:15PM, the Director of Clinical Services, who has the responsibility for activity therapy, stated that "the activity therapist is not required to do any formal assessment, nor is she required to write on the treatment plans in the section titled AT/OT/RT intervention." The Director of Clinical Services also stated, "It is the MHA's that do most of the activities on the unit." Additionally, she reported that there "is no quality monitoring of the AT program" to evaluate its effectiveness.

2. In an interview on 6/7/11 at 4:30PM, patient D14 stated "After 5PM there are no activities scheduled except for AA and NA meetings sometimes. Usually we have some free time after 5PM...get ready for dinner and then go to sleep."

Based on interview, policy review, record review and observations, the facility failed to provide sufficient numbers of activity therapy staff to provide individual patient assessments and staff input into the formulation of the comprehensive treatment plans of 8 of 8 active sample patients (C3, C11, D6, D7, D8, D14, E10 and E11). Inadequate AT staffing results in the absence of therapeutic activities being provided to meet individual patient needs.

Findings include:

A. Interviews

1. During an interview on 6/7/11 at 1PM, the Director of Clinical Services, who has the responsibility for activity therapy, stated that there is "only one Activity Therapist who is a certified recreational therapist who is shared between the three inpatient units and the partial program. The Director of Clinical Services stated that the Activity Therapist is not required to do any formal assessment, nor is she required to write on the treatment plans in the section titled AT/OT/RT intervention, because if she were to do this there would be no time for her to do activities with patients." The Director of Clinical Services further stated "It is the MHA's that do most of the activities on the unit."

2. During an interview on 6/7/11, at 2:15PM, the Director of Nursing (DON) stated that the "nursing staff, primarily the MHA's, are responsible for doing the structured activities that are not done by the activities therapist and that are posted on the unit schedules during the daylight shift, in addition to all evening activities. The DON stated that there was a "breakdown in communication between the nursing staff, concerning a "call off" by the activity therapist on 6/6/11. The DON said that the message was given to the MHA, not the charge nurse on the dual disorders unit, and therefore, no one could answer your [the surveyor's] questions regarding who was responsible for doing the scheduled group and when it would occur.

B. Record Review

1. A review of the active sample patients' medical records (admission dates in parentheses) revealed that none of the records included an assessment done by activity therapy personnel to determine therapeutic/leisure activities required to assist the patient in meeting their individualized treatment goals. The reviewed records were: C3 (6/5/11), C11 (6/2/11), D6 (6/3/11), D7 (6/3/11), D8 (6/4/11), D14 (5/29/11), E10 (5/27/11) and E11 (5/17/11).

2. On Patient C3's pre-printed MTP of 6/6/11, the section titled AT/OT/RT intervention was left blank on the form.

3. On patient C11's pre-printed MTP of 6/3/11, the activities therapist signature was missing. In the pre-printed plans for "psychotic symptoms/delusional thoughts and substance abuse withdrawal." the sections titled AT/OT/RT intervention identified the MHA (mental health assistant) as the discipline responsible for the pre-printed interventions.

4. On patient D6's pre-printed MTP of 6/4/11, for the problem "substance abuse withdrawal," the section titled AT/OT/RT intervention was left blank on the form.

5. On patient D7's pre-printed MTP of 6/6/11, for the problem "substance abuse withdrawal," the section titled AT/OT/RT intervention was left blank on the form.

6. On patient D8's pre-printed MTP of 6/6/11, for the problem "depressive symptoms," the section titled AT/OT/RT intervention was left blank on the form.

7. On patient D14's pre-printed MTP of 5/31/11, for the problem "suicidal thoughts/plan/attempt," the section titled AT/OT/T intervention was left blank on the form.

8. On patient E10's pre-printed MTP of 5/30/11, for the problems "psychotic symptoms/delusional thoughts" and "substance abuse withdrawal," the section titled AT/OT/RT intervention was left blank on the form.

9. On patient E11's pre-printed MTP of 5/17/11, for the problem "disruptive behavior disorder," the section titled AT/OT/RT intervention was left blank on the form.

C. Policy Review

Review of the facility's policy IM4.1, titled "Timeliness of Patient Assessment" (revised 6/07), provided by the Director of Performance Improvement/Risk Management/Health Information Services on 6/6/11, revealed no requirement for discipline specific assessments by activity staff.