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Based on record review and interview, the psychiatric evaluation for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) failed to include an inventory of the patient's assets, written in descriptive non-interpretive fashion. This deficient practice results in a lack of information to guide staff in developing a plan of treatment for the patient.

Findings include:

A. Record Review (psychiatric evaluation dates in parentheses)

In 7 of 8 records reviewed: A1 (10/15/10), A2 (10/13/10), A4 (10/18/10), A5 (10/18/10), A6 (10/22/10), A7 (10/22/10), and A8 (10/19/10), assets were not addressed. For patient A3 (10/17/10), the only asset identified was "Intact verbal skills."

B. Interview

During an interview with the Medical Director on 11/2/10 at 8:35a.m., the lack of asset documentation in the sample patients' psychiatric evaluations was discussed. The Medical Director said that staff psychiatrists were supposed to be documenting strengths/assets in the psychiatric evaluations.

Based on record review and interview, the Medical Director failed to ensure quality control of the psychiatric evaluations conducted by medical staff. Specifically, the Medical Director failed to ensure that the psychiatric evaluations of 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7, A8) included an inventory of patient strengths/asserts. This deficiency results in a lack of information to guide staff in developing a plan of treatment for the patient. (Refer to B117)