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Based on review of the North Carolina General Assembly Statutes (N.C.G.S.), facility list of agency nursing staff, nursing pool contracts and staff interviews, the facility staff failed to ensure 1 of 1 nursing pool agencies (Agency #1) was licensed as required in the state of North Carolina, pursuant to the N.C.G.S. (North Carolina General Statutes).

The findings included:

Review of N.C.G.S. §131E-154.3 titled, "Licensing", last updated on September 27, 2019, revealed, (a) No person shall operate or represent himself to the public as operating a nursing pool without obtaining a license from the Department.

Review on 09/19/2024 of a list of agency nurses currently working at the facility revealed a total of five registered nursing staff working with a nursing pool agency (Agency #1). Review of the list revealed Agency RN #32 had a start date of 08/19/2024 and last date worked was 09/17/2024. Agency RN #30 had a start date of 08/05/2024 and last date worked was 09/18/2024. Agency RN #20 had a start date of 07/15/2024 and last date worked was 09/09/2024. Agency RN #19 had a start date of 06/24/2024 and last date worked was 09/18/2024. Agency RN #31 had a start date of 06/24/2024 and last date worked was 09/17/2024.

Review on 03/04/2020 of a contract between Agency #1 and the hospital revealed it was signed on 05/21/2024.

Interview with Director #6 on 09/19/2024 at 0925 revealed the nurses from Agency #1 were currently working as staff nurses. Interview revealed Agency #1 did not have a nursing pool license and they should have one. Interview revealed this was an oversight and the facility was working on getting a license now that it was discovered they did not have one.

Based on hospital policy review, medical record review, and staff interview, the facility staff failed to exercise patients' rights by not inventorying and dispersing a patient's belongings received at the facility after admission for 2 of 2 sampled patients with lost belongings (Patient #44, Patient #67).

The findings included:

Review on 09/20/2024 of the hospital policy titled "Admission Inventory Process" approved 08/31/2023 revealed "Policy Statement: To provide guidelines for inventory and security of patient's personal belongings. Definitions: Policy: Patients admitted to (Name) will have their personal belongings inventoried at the time of admission. Belongings that are non-essential to the patient's stay on the unit will be sent home with family/legal guardian or will be secured in a secure storage room or safe. Procedure: ... 5. Patient Packages a. Acute Units: Reception staff will notify House Managers of packages via email Monday through Friday and House Supervisors via email on weekends for retrieval. ... 8. Discharge a. Inventory will be checked by unit staff to ensure that all belongings are present at discharge. ..."

Review on 09/20/2024 of the hospital policy titled "Patient' Rights & Responsibilities" approved 08/12/2021 revealed " ... Procedure: 1. Notification of Rights A. At the time of admission, voluntary/involuntary patient or the Legally Responsible Person (LRP) shall be provided a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language. At the time of admission, each patient shall be given written information on the following: ... *A description of a patient grievance procedure. ... C. Unless withheld for therapeutic reasons or under exceptional circumstances, patients are also entitled: *To wear their own clothes and to keep their own possessions if not on the hospital contraband list. ..."

1. Closed medical record review on 09/17/2024 for Patient #44 revealed a 23-year-old male patient involuntary committed to the facility on 11/04/2023 at 1255. Review of a treatment team note signed on 11/06/2023 at 1449 revealed that the clinician reported that patient's mother was concerned about sending clothes, patient rights, and POA (power of attorney). Review of the communication log revealed the mother contacted staff on 11/08/2023 at 1210 to inform staff that a package had been sent to Patient #44 that contained clothes, toothbrush and deodorant. Review of a Clinician note dated 11/13/2023 at 1319 revealed discussion with mother and clinician concerning planned discharge on 11/14/2023. The mother informed the clinician that "clothing had been delivered for the patient on 11/08/2023 and he had still not received them." The clinician informed the mother that the clinician would look into the clothing concern and ensure that the patient got the clothing once located. Review of the medical record revealed a personal belongings inventory sheet was completed and signed during the admission process on 11/04/2023 at 1139 and during the discharge process on 11/14/2023 at 1320. Review of the personal belongings inventory sheets revealed no documentation of an incoming package with personal belongings being received, inventoried or dispersed on 11/08/2023.

Interview on 09/20/2024 at 1515 with PR #27 revealed held Patient Representative role from June 2023 through January 2024 and from February to May 2024 held the Patient Representative and Court Liaison role. PR #27 was requested by the CEO after receiving a certified complaint letter from Patient #44's mother to investigate the concerns. Patient #44 was Involuntary Committed and transferred from an outside hospital to named facility on 11/04/2023. The mother advised that a package with clothes, etc., had arrived at the facility on 11/08/2023 and that the facility claimed that a package had not been received as of 11/11/2023 per the front desk/admissions staff. Patient #44 was given the package on 11/14/2023 at discharge from the facility. The interview revealed that no one at the facility had looked for the patient's package of belongings until the clinician was made aware of the missing package just prior to discharge. The clinician located the package in an admissions storage area and was returned to the Patient and mother at discharge on 11/14/2023. The interview revealed that the issue with personal belongings had been an on-going issue and that no process had been put in place to fix the problem. The interview revealed that the issues/concerns of patient belongings had been discussed in a recent meeting with the Admissions Director and Quality Director as another patient's belongings were given to the wrong patient. The interview revealed that the plan was to update the policy, create a log to track package receipts and re-educate admissions staff. At the time of this interview, the interviewee indicated that there had not been anything put in place for receiving packages.

Interview on 09/20/2024 at 1635 with Director #22 revealed the staff were expected to document any patient packages received from the outside on a log. The director indicated the staff should contact the house supervisor to retrieve the items from admissions and take to the patient's assigned unit. The packages are opened and scanned with wand within the nurses' station. Interview revealed that Director #22 was unable to locate a log in the department that indicated when packages were received from outside the facility.



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2. Closed medical record review on 09/20/2024 for Patient #67 revealed a 9 year old male patient involuntary committed to the facility on 06/03/2024 at 1103. Review of hospital's "Grievance Investigation Form" dated 06/10/2024 (no time noted) revealed Patient #67's mother reported to the facility's patient advocate the mother brought clothes to the hospital for the patient. Review revealed Patient #67 had not received patient's personal belongings for the past eight days. Review of the documentation titled "Interview" revealed on 06/10/2024 at 1410 PR#27 interviewed Patient #67's mother. The patient's mother explained she delivered the patient's book bag to the hospital on "Tuesday, 06/04/2024"around" 2030. The mother stated, "she brought a book bag of clothing and shoes to admissions and asked the person who took the bag to label it." The mother stated, "that the person who accepted the bag said 'We don't do that, the person in the morning does that'." The patient's mother "then explained that the clothing items and a pair of orthopedic crock were lost and her son did not receive them." Continued review revealed PR#27 interviewed Receptionist #24 on 06/10/2024 at 1500. Receptionist #24 stated "she was the one who inventoried the items the following morning, placed the in a white bag with ..." Patient #67's " ...name on it, and then placed the bag into the room behind the admissions office like she always does and then someone else picks up the bag to bring it back to the appropriate unit." PR #27 noted the inventory sheet for Patient #67 was signed by Receptionist #24 however the person that received and delivered the book bag did not sign the inventory sheet. Review of the documentation titled "Investigation Summary" dated 06/12/2024 revealed the allegation of Patient #67's lost personal belongings was substantiated.

Interview on 09/20/2024 at 1515 with PR #27 revealed held Patient Representative role from June 2023 through January 2024 and from February to May 2024 held the Patient Representative and Court Liaison role. The interview revealed that the issue with personal belongings had been an on-going issue and that no process had been put in place to fix the problem. The interview revealed that the issues/concerns of patient belongings had been discussed in a recent meeting with the Admissions Director and Quality Director as another patient's belongings were given to the wrong patient. The interview revealed that the plan was to update the policy, create a log to track package receipts and re-educate admissions staff. At the time of this interview, the interviewee indicated that there had not been anything put in place for receiving packages.

Based on review of Medical Staff Bylaws, medical staff telecare contract, Medical Director Position Description, credentialing files and staff interviews, the hospital's leadership failed to conduct periodic evaluations of the quality of care provided by the hospital's medical staff for 13 of 13 medical staff credentialing files reviewed (DO #28, MD # 29, MD #30, MD #31, NP #32, NP #33, MD #34, NP #4, MD #35, NP # 36, DO #37, MD #38 and NP #39).

The findings included:

Review of the Medical Staff Bylaws approved by the Board of Trustees on 01/25/2022 revealed, "...6.7.3 Content of the Reappointment/Re-credentialing Application Form. The Reappointment/Re-credentialing Application Form shall be a prescribed form and, when completed, shall contain information necessary to maintain, as current, the Medical Staff's file, without limitation, the following information about: (a) objective evidence of the individual's clinical competence based on peer review, quality monitoring, physician profile data activities, and other activities, designed to monitor the efficient and effective delivery of patient care. Such evidence shall include the results of the applicant's ongoing practice review, including data comparison to peers, core measures, outcomes, and focused review outcomes during the prior period of appointment. Practitioners who have not actively practices in this Hospital during the prior appointment period will have the burden of providing evidence of the practitioner's professional practice review, volumes and outcomes from organizations that currently privilege the applicant and where the applicant has actively practiced during the prior period of appointment. ..."

Review of a Telemedicine Services Agreement signed 12/15/2023 revealed, "...4. Customer's and Facilities' Duties. ... f. Credentialing ... g. Document Completion. Provider (defined in contract as the contracted company) and the Clinicians are not required to complete OPPE (Ongoing Professional Practice Evaluations), FPPE (Focused Professional Practice Evaluations) and/or other documents for Facility ..."

Review of the Medical Director's Position Description (not dated) revealed, "... POSITION SUMMARY The Facility Medical Director shall be responsible for the supervision of all health professionals with respect to the administration of the policies and procedures applicable to the inpatient and outpatient programs approved by the facility. He/she assures the adequacy and appropriateness of care given to the patients. ..."

1. Review on 09/13/2024 of DO #28's credentialing file revealed he was a contracted telemed psychiatrist who also served as the Medical Director. Review of the file revealed he was appointed to the medical staff on 10/12/2023 through 10/11/2025. Review of his "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 1 2024 with the number of encounters, number of privileges, number of reported professional events, and number of sentinel events/peer reviews. The review was signed as completed on 03/24/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract company's results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

2. Review on 09/13/2024 of MD #29's credentialing file revealed he was a family medicine physician who had supervising privileges for NP #32. Review of the file revealed he was appointed to the medical staff on 04/24/2024 through 04/23/2026. Review of his file revealed no evidence of professional practice evaluations completed. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there were no professional practice evaluation form in the credentialing file for MD #29.

3. Review on 09/12/2024 of MD #30's credentialing file revealed he was a locums psychiatrist who was no longer employed at the hospital. Review of the file revealed he was appointed to the medical staff on 09/28/2023 through 09/27/2025. Review of his file revealed no professional practice evaluation was found.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there was no professional practice evaluation form in the credentialing file for MD #30.

4. Review on 09/13/2024 of MD #31's credentialing file revealed he was an employed psychiatrist who served as the Chief Medical Officer. Review of the file revealed he was appointed to the medical staff on 08/21/2024 through 08/21/2026. Review of his file revealed no professional practice evaluation was provided. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there was no professional practice evaluation form in the credentialing file for MD #31.

5. Review on 09/13/2024 of NP #32's credentialing file revealed she was a nurse practitioner who was employed to provide medical evaluation and care to the patients. Review of the file revealed she was appointed to the medical staff on 02/22/2024 through 02/21/2026. Review of her file revealed no evidence of professional practice evaluation completed. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the professional practice evaluation form was not in the credentialing file for NP #32.

6. Review on 09/13/2024 of NP #33's credentialing file revealed she was a contracted telemed nurse practitioner who provided psychiatry services. Review of the file revealed she was appointed to the medical staff on 04/24/2024 through 04/23/2026. Review of his "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 3 2024 with the number of encounters, number of privileges,and number of sentinel events/peer reviews. The review was signed as completed on 08/28/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract companys results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

7. Review on 09/17/2024 of MD #34's credentialing file revealed she was a contracted telemed psychiatrist. Review of the file revealed she was appointed to the medical staff on 03/11/2024 through 03/10/2026. Review of her "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 3 2024 with the number of encounters, number of privileges, and number of sentinel events/peer reviews. The review was signed as completed on 07/31/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract companys results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

8. Review on 09/17/2024 of NP #4's credentialing file revealed she was a contracted telemed nurse practitioner. Review of the file revealed she was appointed to the medical staff on 04/24/2024 through 04/23/2026. Review of her "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 3 2024 with the number of encounters, number of privileges, and number of sentinel events/peer reviews. The review was signed as completed on 08/29/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract companys results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

9. Review on 09/17/2024 of MD #35's credentialing file revealed he was a locums who was a family medicine physician.. Review of the file revealed he was appointed to the medical staff on 08/12/2024 through 11/12/2024. Review of his file revealed there were no professional practice evaluations completed. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there was no professional practice evaluation forms that were in the credentialing file for MD #35.

10. Review on 09/17/2024 of NP #36's credentialing file revealed she was a contracted telemed nurse practitioner who provided psychiatry services. Review of the file revealed she was appointed to the medical staff on 03/11/2024 through 03/10/2026. Review of her "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 3 2024 with the number of encounters, number of privileges, and number of sentinel events/peer reviews. The review was signed as completed on 08/28/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract companys results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

11. Review on 09/13/2024 of DO #37's credentialing file revealed she was a contracted telemed psychiatrist. Review of the file revealed she was appointed to the medical staff on 04/24/2024 through 04/23/2026. Review of his "Professional Practice Evaluation (FPPE and OPPE) 2024 Provider Compliance Form" provided by the telecare contracted service revealed the evaluation was completed on quarter 1 2024 with the number of encounters, number of privileges, number of reported professional events, and number of sentinel events/peer reviews. The review was signed as completed on 04/07/2024. Review revealed evaluation of the provider's performance with the telemed contract service. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed the Professional Practice Evaluation forms that were in the credentialing files did not provide data or quality review of the provider's performance for this facility. Interview revealed that data represented the contract companys results for the individual provider for all contracted locations. There were no specific data that was measured for this psychiatric hospital. The number of encounters were the total number of encounters that the provider had for the contracted service and not for this hospital. The hospital staff were unable to define what the number of privileges represented. The hospital staff were unable to explain how the numbers related to the quality of care provided to patients.

12. Review on 09/17/2024 of MD #38's credentialing file revealed he was a contracted telemed psychiatrist. Review of the file revealed he was appointed 02/29/2024 through 02/28/2026. Review of his file revealed no professional practice evaluation was provided. There was no evidence of the evaluation of care provided to the hospital's patients.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there was no professional practice evaluation forms that were in the credentialing file for MD #38.

13. Review on 09/19/2024 of NP #39's credentialing file revealed she was a nurse practitioner who provided psychiatric care. Review of the file revealed she was appointed 09/29/2023 through 09/28/2025. Review of her file revelaed no professional practice evaluation.

Interview on 09/28/2024 at 1547 with Director #6 and the Chief Operating Officer (COO) revealed there was no professional practice evaluation form in the credentialing file for NP #39.

Based on review of Medical Staff Bylaws, Medical Executive Committee (MEC) Meeting minutes, and staff interview, the Medical staff failed to have designated attendance and representation of the Medical Staff at 10 of 10 MEC Meetings minutes reviewed.

The findings included:

Review of the Medical Staff Bylaws adopted and approved 01/25/2022 by the Board of Trustees revealed, "...11.2 MEDICAL EXECUTIVE COMMITTEE. 11.2.1 Compisition. MEC shall consist of Members, a majority of who shall be fully licensed physician Membbers of the Active Staff. The Medical Director shall be a member and chaiman of the MEC. ... The remaining Members of the Committee shall be: (a) The President of the Staff; (b) the Vice-Oresident of the staff (if any); (c) the Secretary Treasurer of the Staff; and (d) up to (3) Members of the Active Staff who are elected by the Staff to serve on the MEC for one (1) year ... 11.2.2 Duties. ... The duties of the MEC shall be to: ... (e) account to the Board and to the Staff for the overall quality, uniformity, and efficiency of medical care rendered to patients; ..."

Review of Medical Executive Committee meeting minutes dated October 13, 2023 revealed an emergency credentialing meeting was held. Review of the meeting minutes reveled no physician was present.

Review of Medical Executive Committee meeting minutes dated October 26, 2023 revealed a MEC meeting was held. Review of the meeting minutes reveled one physician (Medical Director) was present.

Review of Medical Executive Committee meeting minutes dated November 30, 2023 revealed a MEC meeting was held. Review of the meeting minutes reveled one physician (Medical Director) and one Physician Assistant was present.

Review of Medical Executive Committee meeting minutes dated January 4, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled one physician (Medical Director) and one Physician Assistant was present.

Review of Medical Executive Committee meeting minutes dated January 25, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled one physician (Medical Director) was present.

Review of Medical Executive Committee meeting minutes dated February 22, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled two physicians (Medical Director of Acute and Medical Director of PRTF) were present.

Review of Medical Executive Committee meeting minutes dated March 28, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled three physicians (Medical Director and two additional physicians) were present.

Review of Medical Executive Committee meeting minutes dated April 25, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled three physicians (Medical Director and two additional physicians) were present.

Review of Medical Executive Committee meeting minutes dated July 25, 2024 revealed a MEC meeting was held. Review of the meeting minutes reveled two physicians (Medical Director and one additional physician) were present.

Review of Medical Executive Committee meeting minutes dated August 21, 2024 revealed an emergency MEC meeting was held. Review of the meeting minutes reveled two physicians (Medical Director and one additional physician) were present.

Interview on 09/18/2024 at 1547 with the Interim CEO during the time of the MEC Meetings identified and the Director of Risk Management revealed the Medical staff Bylaws required three medical staff members and the Medical Director to attend the MEC Meetings. Interview revealed the Medical Director was the only medical staff member present during some of the MEC meetings in 2023 and the medical staff failed to be in attendance according the the Bylaws for MEC meetings in 2024.

Based on a review of facility policy, medical records reviews, and staff interview, the facility staff failed to document the patient's (pt) stated goal on the master treatment plan for 2 of 82 sampled patients reviewed (Pt #71, Pt#12).

The findings included:

Review on 09/20/2024 of facility policy "Interdisciplinary Patient-Centered Care Planning - Acute," last reviewed 03/06/2023, revealed, "... Developing the Treatment Plan ... 3. The social services staff member assigned to the patient will be responsible for meeting with the patient and family/representative, if appropriate prior to the MTP (master treatment plan) meeting to obtain their goals for treatment ..."

1. Closed medical record review on 09/19/2024 for Pt#71 revealed a 13-year-old female admitted to the facility on 07/25/2024 with a diagnosis of major depressive disorder and suicidal ideation. Review of the medical record revealed the interdisciplinary MTP was initiated on 07/26/2024. Review of the treatment plan problem sheets revealed the patient-stated goal was documented as "N/A" (not applicable). Pt#71 was discharged home on 08027/2024.

Interview on 09/20/2024 at 1335 with Director#1 revealed goals should be included in the MTP. Interview revealed the patient-stated goal should not be documented as "N/A."



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2. Closed medical record review on 09/10/2024 for Pt#12 revealed a 17-year-old female admitted to the facility on 11/08/2023 at 2210 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings) and suicidal ideation. Review of the medical record revealed the interdisciplinary MTP was initiated on 11/09/2023. Review of the treatment plan problem sheets revealed the patient-stated goal was documented as "N/A" (not applicable). Pt#12 was discharged home on 11/17/2023 at 1348.

Interview on 09/20/2024 at 1335 with the Director#1 revealed goals should be included in the MTP. Interview revealed the patient-stated goal should not be documented as "N/A."

Based on medical staff rules and regulations review, medical record reviews, and staff interview, the facility failed to ensure a psychiatric evaluation was reviewed and countersigned by a psychiatrist for 12 of 82 sampled patients (Pt #1, Pt #2, Pt #3, Pt #21, Pt #37, Pt #39, Pt #45, Pt #27, Pt #10, Pt#15, Pt #62, and Pt #63).

The findings included:

Review of the "MEDICAL STAFF RULES AND REGULATIONS" signed 09/12/2024 revealed, "... 2.6 The Psychiatric Evaluation shall be completed within 24 hours of admission to inpatient care or RTC (return to care) by the attending/covering psychiatrist or physician extender with appropriate privileges. ... The attending psychiatrist or covering psychiatrist must assess each patient within 24 hours of admission and finalize the psychiatric evaluation by reviewing/approving any portion delegated to a Nurse Practitioner or Clinical Nurse Specialist and ensuring that the evaluation is thoroughly completed so that is meets all standards and contains sufficient information to justify the psychiatric diagnosis and treatment. ..."

Review on 09/13/2024 of the facility's "Medical Staff Rules and Regulations," dated 03/2023, revealed, "... 2.6 ... The attending psychiatrist or covering psychiatrist must assess each patient within 24 hours of admission and finalize the psychiatric evaluation by reviewing/approving any portion delegated to a Nurse Practitioner or Clinical Nurse Specialist and ensuring that the evaluation is thoroughly completed so that is (sic) meets all standards and contains sufficient information to justify the psychiatric diagnosis and treatment ..."

1. Closed medical record review on 09/10/2024 for Pt #1 revealed a 15-year-old male admitted to the facility on 07/19/2024 under IVC (involuntary commitment) for suicidal ideation attempts and eloped from Hospital B on 07/24/2024. Patient #1 had a Psychiatric evaluation documented by NP #3 on 07/20/2024 at 0401 that did not address Patient #1's assets. The Psychiatric evaluation was not cosigned by a physician.

2. Closed medical record review on 09/10/2024 for Pt #2 revealed a 16-year-old male admitted to the facility on 06/05/2024 under IVC for aggressive behavior and homicidal ideations. Pt #2 was discharged on 07/24/2024. Patient #2 had a Psychiatric evaluation documented by NP #4 on 07/20/2024 at 0401. The Psychiatric evaluation was not cosigned by a physician.

3. Closed medical record review on 09/11/2024 for Pt #3 revealed a 13-year-old male admitted to the facility on 07/18/2024 under IVC for aggressive behavior was discharged on 07/31/2024. Pt #3 had a Psychiatric evaluation documented by NP #4 on 07/19/2024 at 1219. The Psychiatric evaluation was not cosigned by a physician.

4. Closed medical record review on 09/13/2024 for Pt #21 revealed a 14-year-old male admitted to the facility on 07/17/2024 under IVC for suicidal ideation with a plan and discharged on 07/26/2024. Patient #21 had a Psychiatric evaluation documented by NP #8 on 07/18/2024 at 0704 that did not address Patient #21's assets. The Psychiatric evaluation was not cosigned by a physician.

5. Open medical record review on 09/11/2024 for Pt #37 revealed a 14-year-old male admitted to the facility on 09/01/2024 under IVC for suicidal ideation attempt. Pt #37 had a Psychiatric evaluation documented by NP #4 on 09/05/2024 at 1025. The Psychiatric evaluation was not cosigned by a physician.

6. Open medical record review on 09/12/2024 for Pt #39 revealed a 16-year-old male admitted to the facility on 09/06/2024 under IVC for depressive symptoms. Pt #39 had a Psychiatric evaluation documented by NP #7 on 09/07/2024 at 0400. The Psychiatric evaluation was not cosigned by a physician.

7. Closed medical record review on 09/17/2024 for Pt #45 revealed an 66-year-old female admitted to the facility on 05/24/2024 under IVC with a diagnosis of "Bipolar disorder, current episode, manic without psychotic features" and was discharged on 06/04/2024. Patient #45 had a Psychiatric evaluation documented by NP #2 on 05/26/2024 at 0444 that did not address Patient #45's assets. The Psychiatric evaluation was not cosigned by a physician.



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8. Medical record review on 09/13/2024 for Pt #27 revealed a 35-year-old female admitted to the facility on 09/05/2024 at 1718 with a diagnosis of major depressive disorder. Record review revealed the Psychiatric Evaluation was documented by the Nurse Practitioner on 09/10/2024 at 1621 and was not cosigned by the Physician. Pt #27 was discharged home on 09/13/2024 at 1105.

9. Closed medical record review on 09/10/2024 for Pt#10 revealed a 14-year-old female admitted to the facility on 11/02/2023 at 2330 with a diagnosis of bipolar disorder (characterized by severe mood swings). Record review revealed the Psychiatric Evaluation was documented by the Physician Assistant on 11/03/2023 at 1710 and was not cosigned by the Physician. Pt #10 was discharged into the care of the Department of Social Services on 11/9/2023 at 1948.

10. Closed medical record review on 09/11/2024 for Pt #15 revealed a 17-year-old female admitted to the facility on 11/02/2023 at 2135 with a diagnosis of disruptive mood dysregulation disorder. Record review revealed the Psychiatric Evaluation was documented by the Physician Assistant on 11/03/2023 at 1637 and was not cosigned by the Physician. Pt #15 was discharged home on 11/09/2023 at 1811.

11. Closed medical record review on 09/17/2024 for Pt #62 revealed an 11-year-old female admitted to the facility on 10/13/2023 at 1020 with a diagnosis of disruptive mood dysregulation disorder and suicidal ideation. Record review revealed the Psychiatric Evaluation was documented by the Nurse Practitioner on 10/13/2023 at 1400 and was not cosigned by the Physician. Pt #62 was discharged home on 10/19/2023 at 1500.

12. Closed medical record review on 09/17/2024 for Pt #63 revealed a 9-year-old male admitted to the facility on 10/12/2023 at 1834 with a diagnosis of disruptive mood dysregulation disorder (persistently angry mood and frequent temper outbursts). Record review revealed the Psychiatric Evaluation was documented on 10/13/2023 at 1045 by the Nurse Practitioner and was not cosigned by the Physician. Pt #63 was discharged home on 11/08/2023 at 1240.

Based on facility policy review, medical staff rules and regulations, medical record reviews and interviews, the facility staff failed to complete a psychiatric evaluation for 5 of 82 patient records reviewed (Pt. #44, #27, #13, #66, #51)

The findings included:

Review on 09/18/2024 of the facility policy titled "Multidisciplinary Documentation and Assessment Standards" approved 08/12/2021 revealed "... Psychiatric Evaluation Within 24 hours ..."

Review on 09/13/2024 of the facility's "Medical Staff Rules and Regulations," dated 03/2023, revealed, "... 2.6 ... The Psychiatric Evaluation shall be completed within 24 hours of admission ..."

1. Review on 09/17/2024 of the medical record for Patient #44 revealed a 23-year-old male admitted to the facility on 11/04/2023 at 1255 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed no documentation of a psychiatric evaluation completed by the admitting physician. Patient #44 was discharge home on 11/14/2023 at 1320.

Interview on 09/19/2024 with Director #6 revealed the staff were unable to locate a psychiatric evaluation in the medical record. Interview revealed the expectation was that the providers complete the psychiatric evaluations within 24 hours of admission.



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2. Medical record review on 09/13/2024 for Pt #27 revealed a 35-year-old female admitted to the facility on 09/05/2024 at 1718 with a diagnosis of major depressive disorder. Record review revealed the Psychiatric Evaluation was documented by the Nurse Practitioner on 09/10/2024 at 1621. Pt #27 was discharged home on 09/13/2024 at 1105.

Interview on 09/13/2024 at 1203 with Director #9 revealed the expectation that psychiatric evaluations were to be completed within 24 hours and placed in the patient's medical record.

Interview on 09/20/2024 at 1335 with Director #1 revealed the physician was responsible for ensuring the psychiatric evaluation was completed within 24 hours of admission.

3. Closed medical record review on 09/10/2024 for Patient #13 (pt) revealed a 12-year-old female admitted to the facility on 10/27/2023 at 1915 with a diagnosis of major depressive disorder and suicidal ideation. Review of the medical record revealed no documentation of a psychiatric evaluation completed by the provider. Pt#13 was discharged home on 11/16/2023 at 1220.

Interview on 09/13/2024 at 1203 with Director #9 revealed the expectation that psychiatric evaluations were to be completed within 24 hours and placed in the patient's medical record.

Interview on 09/20/2024 at 1335 with Director #1 revealed the physician was responsible for ensuring the psychiatric evaluation was completed within 24 hours of admission.

4. Closed medical record review on 09/17/2024 for Patient #66 (pt) revealed a 16-year-old female admitted to the facility on 11/14/2023 at 0958 with a diagnosis of major depressive disorder and suicidal ideation. Review of the medical record revealed no documentation of a psychiatric evaluation completed by the provider. Pt #66 was discharged home on 11/22/2023 at 1736.

Interview on 09/13/2024 at 1203 with Director #9 revealed the expectation that psychiatric evaluations were to be completed within 24 hours and placed in the patient's medical record.

Interview on 09/20/2024 at 1335 with Director#1 revealed the physician was responsible for ensuring the psychiatric evaluation was completed within 24 hours of admission.

MD #18 was not available for interview.



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5. A closed medical record review for Patient #51 (pt) revealed a 22-year-old female admitted to the facility on 12/10/2023 under an IVC order for suicidal ideation with history of schizoaffective disorder, bipolar type and borderline personality disorder. Review of the
medical record revealed no documentation of a psychiatric evaluation completed by the provider. Pt #51 was discharged home on 12/13/2023.

Interview on 09/19/2024 at 1220 with RN #19 revealed the staff were unable to locate a psychiatric evaluation in the medical record. Interview revealed the expectation was that the providers complete the psychiatric evaluations within 24 hours of admission.

Based on policy review, Medical Staff Rules and Regulations review, medical record review and staff interview, facility staff failed to ensure an inventory of the patient's assets were included in the psychiatric evaluation for 5 of 82 medical records reviewed (#52, #53, #1, #21 and #45).

The findings included:

Review of the "Interdisciplinary Patient-Centered Care Planning - Acute" policy approved 03/23/2023 revealed, "... Policy: It is the policy of (Hospital name) to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. ..."

Review of the "MEDICAL STAFF RULES AND REGULATIONS" signed 09/12/2024 revealed, "... The psychiatric evaluation shall be completed within 24 hours of admission to inpatient care ... 2.6.1 The psychiatric evaluation should include the following elements: ...o. Patient assets (specific assets or personal factors on which to base the treatment plan or which are useful in therapy) ..."

1. Review of a closed medical record review for Patient #52 revealed a 17-year-old male admitted to the facility on 01/19/2024 under an IVC (involuntary committment) order for suicidal ideations with a diagnosis of Major Depressive Disorder (MDD). Review of the initial psychiatric evaluation dated 01/19/24 revealed that no assets were documented. Review revealed the patient was discharged on 01/31/2024.

Interview on 09/19/2024 at 1220 with RN #19 confirmed that pt #52 did not have assets listed on pt #52's initial psychiatric evaluation.

2. Review of a closed medical record review for Patient #53 revealed a 14-year-old female admitted to the facility on 01/25/2024 under an IVC order for suicidal ideations with a diagnosis of bipolar disorder. Review of the initial psychiatric evaluation dated 01/26/24 revealed that no assets were documented. Patient #53 was discharged on 02/23/2024

Interview on 09/19/2024 at 1220 with RN #19 confirmed that pt #53 did not have assets listed on pt # 53's initial psychiatric evaluation.



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3. Closed medical record review on 09/10/2024 for Pt #1 revealed a 15-year-old male admitted to the facility on 07/19/2024 under IVC (involuntary commitment) for suicidal ideation attempts and eloped from Hospital B on 07/24/2024. Patient #1 had a Psychiatric evaluation documented by NP #3 on 07/20/2024 at 0401 that did not address Patient #1's assets.

Interview on 09/19/2024 with RN #10 confirmed that pt #1 did not have assets listed on pt #52's initial psychiatric evaluation.

4. Closed medical record review on 09/13/2024 for Pt #21 revealed a 14-year-old male admitted to the facility on 07/17/2024 under IVC for suicidal ideation with a plan and discharged on 07/26/2024. Patient #21 had a Psychiatric evaluation documented by NP #8 on 07/18/2024 at 0704 that did not address Patient #21's assets.

Interview on 09/19/2024 with RN #10 confirmed that pt #21 did not have assets listed on pt #52's initial psychiatric evaluation.

5. Closed medical record review on 09/17/2024 for Pt #45 revealed an 66-year-old female admitted to the facility on 05/24/2024 under IVC with a diagnosis of "Bipolar disorder, current episode, manic without psychotic features" and was discharged on 06/04/2024. Patient #45 had a Psychiatric evaluation documented by NP #2 on 05/26/2024 at 0444 that did not address Patient #45's assets.

Interview on 09/19/2024 with RN #10 confirmed that pt #45 did not have assets listed on pt #52's initial psychiatric evaluation.

Based on review of facility policy, medical records and staff interviews, the facility staff failed to ensure a Master Treatment Plan was completed and/or updated and/or included medical diagnosis for 40 of 82 medical records reviewed (Pt #34, Pt #77, Pt #44, Pt #75, Pt #76, Pt #31, Pt #58, Pt #60, Pt #59, Pt #46, Pt #73, Pt #2, Pt #3, Pt #19, Pt #40, Pt #8, Pt #9, Pt #27, Pt #13, Pt #66, Pt #17, Pt #11, Pt #16, Pt #65, Pt #63, Pt #64, Pt #12, Pt #14, Pt #62, Pt #15, Pt #55, Pt #52, Pt #53, Pt #5, Pt #68, Pt #67, Pt #26, Pt #70, Pt #71, Pt #25 ).

The findings include:

Review on 09/12/2024 of the policy titled "Interdisciplinary Patient-Centered Care Planning" approved 3/23/2023, revealed "..Procedure...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ...The treatment team will complete the MTP (Master Treatment Plan) including: a. Completion of diagnosis, problem list, and patient assets ...b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheet will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. ... 5. The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in the development of the plan ... Interdisciplinary Treatment Plan Update 1. Treatment Plan Review The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days. Identified problems will be summarized, progress towards goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated. ... A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision: ... A major change occurs in the patient's clinical condition, such as the need for the use of restraint or seclusion. ... The patient fails to reach treatment goals despite reasonable clinical care. ... The treatment team determines the patient's current treatment plan would more appropriately be delivered on an individual basis rather than group interventions. 2. Resolving, Discontinuing or Continuing Goals and Interventions ... Once a goal has been resolved, the date will be identified on the treatment plan ... c. Staff members upon discharge, shall either document on remaining goals the date if resolved or 'ongoing' meaning that the problem has not yet been resolved. ..."

1. Open medical record review on 09/12/2024 and closed record review on 09/18/2024 for Patient #34 revealed a 10-year-old female involuntary committed to the facility on 09/04/2024 at 2221 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed the Master Treatment Plan (MTP) psychiatric diagnosis was documented on 09/04/2024. The MTP master psychiatric problem list was completed on 09/06/2024 after discussion with between the Care coordinator/Therapist and Patient #34. A Treatment Team Meeting was held on 09/09/2024. Record review revealed no documentation of a 7-day treatment plan review. Patient #34 was discharged to home with family on 09/17/2024 at 1240.

Interview on 09/20/2024 at 1000 with NM (Nurse Manager) #26 revealed the treatment plan for Patient #34 was initiated on 09/06/2024 with the patient and the social worker. The treatment team meeting was held on 09/09/2024. Interview revealed the NM was unable to locate an updated treatment plan in the medical record prior to discharge on 09/17/2024.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

2. Closed medical record review on 09/20/2024 for Patient #77 revealed a 14-year-old male involuntary committed to the facility on 06/18/2024 at 1240 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed no evidence of a psychiatric diagnosis documented on the Master Treatment Plan. The MTP master psychiatric problem list was completed on 06/18/2024. A Treatment Team Meeting was held on 06/20/2024. Record review revealed no documentation of a 7-day treatment plan review. Patient #77 was discharged to home with family on 06/28/2024 at 1159.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

3. Closed medical record review on 09/17/2024 for Patient #44 revealed a 23-year-old male involuntary committed to the facility on 11/04/2023 at 1255 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed the Master Treatment Plan psychiatric diagnosis was documented on 11/04/2023. The treatment plan master psychiatric problem list was completed on 11/04/2023. A medical diagnosis was added to the problem identifier list on 11/06/2023. The master treatment plan short-term goals were documented on 11/08/2023 (96 hours after admission). A Treatment Team Meeting was held on 11/09/2023. Record review revealed no updated treatment plan documentation prior to discharge. Record review revealed no documentation of the medical diagnosis added to the interdisciplinary master treatment plan. Patient #44 was discharged to home with family on 11/14/2023 at 1320.

Interview on 09/20/2024 at 1000 with NM (Nurse Manager) #26 revealed the treatment plan for Patient #44 was initiated on 11/08/2023 with the patient and the social worker. The treatment team meeting was held on 11/09/2023. The NM indicated the treatment plan was not intiated within 72 hours of admission. The NM revealed the facility policy was not followed.

4. Closed medical record review on 09/19/2024 for Patient #75 revealed a 13-year-old female admitted to the facility on 10/23/2023 at 1745 with a diagnosis of Disruptive Mood Dysregulation Disorder. Review of the medical record revealed the Master Treatment Plan psychiatric diagnosis was documented on 10/23/2023. The medical problem list was completed on 10/25/2023. The MTP master psychiatric problem list was completed on 10/26/2023. Review of the Interdisciplinary Treatment Team Plan revealed the treatment team meeting section was signed by the care coordinator/therapist on 10/26/2023 and by the recreational therapist on 10/27/2023. The review revealed no provider or nurse signature. Record review revealed no documentation of a 7-day treatment plan review documented on 10/30/2023 or 11/06/2023. Review of the master treatment plan update/clinical staffing worksheet dated 11/07/2023 revealed documenting of a nursing update with no evidence of a psychiatric, clinical staffing or social services update and no signatures of the treatment team members. Patient #75 was discharged on 11/13/2023 at 1422.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

5. Closed medical record review on 09/19/2024 for Patient #76 revealed a 15-year-old male involuntary committed to the facility on 10/23/2023 at 1338 with a diagnosis of Disruptive Mood Dysregulation Disorder. Review of the medical record revealed the Master Treatment Plan psychiatric diagnosis was documented on 10/23/2023. The MTP master psychiatric problem list was completed on 10/24/2023. The medical problem list was completed on 10/27/2023. Review of the Interdisciplinary Treatment Team Plan revealed the treatment team meeting section was signed by the care coordinator/therapist on 10/24/2023 and by the recreational therapist on 10/24/2023. The review revealed no provider or nurse signature. Record review revealed no documentation of a 7-day treatment plan review documented on 10/30/2023 or 11/06/2023. Review of the master treatment plan update/clinical staffing worksheet dated 10/30/2023 revealed documenting of a nursing update with no evidence of a psychiatric, clinical staffing or social services update and no signatures of the treatment team members. Patient #76 was discharged on 11/07/2023 at 0302.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."



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6. An open medical record for Patient #31 revealed a 16-year-old female admitted to the facility on 09/01/2024 under an IVC order for self harm. Patient #31 was recently removed from parent's home after sexual abuse and trafficking. A review of the MTP revealed an initial date of 09/01/2024 with a problem list of Major Depressive Disorder and chronic PTSD (Post Traumatic Stress Disorder). No additional updates were documented. The review revealed that Patient #31 remained inpatient on 09/12/2024. The review revealed that the facility failed to provide a master treatment plan update every seven days for Patient #31 per the facility policy.

Interview on 09/12/2024 at 1000 with RN #5 revealed Master Treatment Plans (MTP) are updated every 7 days. Interview confirmed this MTP was not updated every 7 days.



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7. A closed medical record for Patient #58 revealed a 35-year-old male admitted to the facility on 01/31/2024 under an IVC order for having auditory command hallucinations to hurt himself and others with the diagnosis of Schizoaffective disorder. A review of the MTP revealed an initial date of 02/01/2024 with a problem list of Psychosis and Homicidal Ideations. The review revealed the Master Treatment Plan updates were documented on 02/6/2024 (5 days after the initial treatment plan), 02/27/2024 (21 days after the last update), 03/05/2024 (7 days after the previous update), 03/21/2024 (16 days after the last update), and 03/25/2024 (4 days after the previous update). No additional updates were noted until discharge. The review revealed that Patient #58 was discharged from the facility on 06/24/2024. The review revealed that the facility failed to provide a master treatment plan update every seven days for Patient #58 per the facility policy.

An interview on 09/20/2024 at 1330 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions.

A follow-up interview on 09/20/2024 at 1500 with Director #1 confirmed that the master treatment plan updates could not be located. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

8. A closed medical record review on 09/17/2024 for Patient #60 revealed a 19-year-old female admitted to the facility on 01/10/2024 under an IVC order for having Auditory Hallucinations with a diagnosis of unspecified Psychosis. A review of the MTP revealed an initial date of 01/13/2024 with a problem list of Homicidal Ideations (HI) and Auditory/Visual Hallucination (AVH). The review revealed the Master Treatment Plan updates were documented on 01/23/2024 and 02/06/2024. The review revealed that Patient #60 was discharged from the facility on 05/01/2024. The review revealed that the facility failed to provide a master treatment plan update every seven days for Patient #60 per the facility policy.

An interview on 09/20/2024 at 1330 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions.

A follow-up interview on 09/20/2024 at 1500 with Director #1 confirmed that the master treatment plan updates could not be located. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

9. A closed medical record review on 09/18/2024 for Patient #59 revealed a 26-year-old male admitted to the facility on 02/15/2024 voluntarily for having Auditory Hallucinations to commit a mass shooting with a diagnosis of Schizophrenia. A review of the MTP revealed an initial date of 02/15/2024 with a problem list of Homicidal Ideations (HI) and Auditory/Visual Hallucination (AVH). The review revealed no Master Treatment Plan updates were documented and Patient #59 was discharged on 02/27/2024 (12 days after the initial Master plan).

An interview on 09/20/2024 at 1330 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions.

A follow-up interview on 09/20/2024 at 1500 with Director #1 confirmed that the master treatment plan updates could not be located. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

10. A closed medical record review on 09/18/2024 for Patient #46 revealed an 18-year-old female admitted to the facility on 11/19/2023 under an involuntary order for having suicidal ideations with a diagnosis of Major Depressive Disorder. A review of the MTP revealed an initial date of 11/22/2023 with a problem list of Self-Injurious Behavior and Suicidal Ideations. The review revealed the Master Treatment Plan updates were documented on 12/04/2023 (12 days after the initial Master Treatment Plan) and 12/18/2023 (14 days after the last update). The review revealed that Patient #46 was discharged from the facility on 12/22/2023. The review revealed that the facility failed to provide a master treatment plan update every seven days for Patient #46 per the facility policy.

An interview on 09/20/2024 at 1330 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions.

A follow-up interview on 09/20/2024 at 1500 with Director #1 confirmed that the master treatment plan updates could not be located. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

11. A closed medical record for Patient #73 revealed a 37-year-old female admitted to the facility on 12/06/2023 under an IVC order for concerns related to psychotic decompensation, non-compliance with medications, increased aggression, and eloping from a group home. Patient #73 was admitted with a diagnosis of Schizophrenia, Acute Psychosis, and Anxiety. A review of the MTP revealed an initial date of 12/08/2023 with a problem list of Psychosis and Aggression. The review revealed the Master Treatment Plan updates were documented on 12/28/2024 28 days after the initial master treatment plan), 01/02/2024 (5 days after the previous treatment update), 01/23/2024 (21 days after the previous update), 01/30/2024 (7 days after the last update), 02/06/2024 (7 days after the previous treatment update), 02/27/2024 (21 days after the last update), and 03/05/2024 (7 days after the previous treatment update). The review revealed that Patient #73 was discharged from the facility on 03/11/2024 to a state hospital. The review revealed that the facility failed to provide a master treatment plan update every seven days for Patient #73 per the facility policy.

An interview on 09/20/2024 at 1330 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions.

A follow-up interview on 09/20/2024 at 1500 with Director #1 confirmed that the master treatment plan updates could not be located. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."



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12. Closed medical record review on 09/10/2024 for Pt #2 revealed a 16-year-old male admitted to the facility on 06/05/2024 under IVC for aggressive behavior and homicidal ideations. Pt #2 was discharged on 07/25/2024. The Master Treatment Plan (MTP) was created and signed on 06/06/2024. Review revealed there were no updates to the MTP and there was no indication if the goals were achieved or discontinued.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

13. Closed medical record review on 09/11/2024 for Pt #3 revealed a 13-year-old male admitted to the facility on 07/18/2024 under IVC for aggressive behavior was discharged on 07/31/2024. The Master Treatment Plan (MTP) was created and signed on 07/22/2024. Review revealed there were no updates to the MTP and there was no indication if the goals were achieved or discontinued.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

14. Closed medical record review on 09/13/2024 for Pt #19 revealed a 17-year-old male admitted to the facility on 06/14/2024 under IVC for aggressiveness and was discharged on 08/15/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 06/18/2024, the Psychiatrist was "via zoom", the Nurse Practitioner was "via zoom" and was signed by Pt #19 on 06/18/2024. Review revealed there was a Master Treatment Plan Update/Clinical Staffing Worksheet dated 08/09/2024. The MTP Update was not filled out under "Psychiatrist Update" or the "Social Services Update". The MTP Update was not signed by either entity and there was no documentation it was shared with Pt #19 nor Pt #19's guardian. Review revealed there were no other MTP Updates in Pt #19's medical record. Review revealed there were no updates to the MTP and there was no indication if the goals were achieved or discontinued.

Interview on 09/20/2024 at 1335 with Director #1 revealed that the master treatment plan should be updated every seven days involving the Psychiatrist, the Clinician, the Nurse, and the patient/family when possible. The interview revealed if a patient was not making progress and set goals were not met, the update should reflect the lack of progress, and the team should implement new interventions. The interview revealed from conversations between Director #1 and the teams, "I (Director #1) had been informed that the teams were meeting every seven days, but they were not completing the seven-day update forms."

15. Open medical record review on 09/12/2024 for Pt #40 revealed a 15-year-old male admitted to the facility on 09/05/2024 under IVC for suicidal ideations and cutting. There was no Psychiatric evaluation in the medical record.

Interview on 09/13/2024 at 1203 with Director #9 revealed the expectation that psychiatric evaluations were to be completed within 24 hours and placed in the patient's medical record.

Interview on 09/20/2024 at 1335 with Director #1 revealed the physician was responsible for ensuring the psychiatric evaluation was completed within 24 hours of admission.



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16. Closed medical record review of Patient #8 revealed a 13-year-old male involuntarily committed on 05/16/2024 for suicidal ideation. Review of the MTP revealed an initial date of 05/17/2024 and an updated MTP on 05/23/2024. Review of the updated MTP revealed no documentation of progress towards goals or new goals identified and no updated discharge considerations were documented as per the facility policy. Record review revealed the patient was discharged home on 05/30/2024.

Interview on 09/12/2024 at 1140 with Director #6 revealed the MTP should be updated at a minimum of every 7 days.

17. Closed medical record review of Patient #9 revealed a 17-year-old male involuntarily committed on 05/21/2024 for suicidal ideation and auditory hallucinations. Review of the MTP revealed an initial completion date of 05/24/2024. No updates were documented. Record review revealed the patient was discharged 06/01/2024 (8 days after initial MTP). Record review revealed no updated MTP was completed every 7 days per the facility policy.

Interview on 09/12/2024 at 1140 with Director #6 revealed the MTP should be updated at a minimum of every 7 days.



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18. Medical record review on 09/13/2024 for Pt #27 revealed a 35-year-old female admitted to the facility on 09/05/2024 at 1718 with a diagnosis of major depressive disorder. Review of the medical record revealed the MTP was developed on 09/09/2024 (4 days after admission). Pt #27 was discharged home on 09/13/2024 at 1105. Review of the treatment plan problem sheets revealed no documentation of the date Pt#27's goals were achieved or discontinued.

Interview on 09/17/2024 at 1020 with Director#1 revealed the expectation that each short-term goal on the treatment plan problem sheets should have documentation of the date the goal was achieved. The interview revealed if a goal was not achieved, there should be a note documented.

Follow-up interview on 09/20/2024 at 1335 with Director#1 revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team.

19. Closed medical record review on 09/10/2024 for Pt #13 revealed a 12-year-old female admitted to the facility on 10/27/2023 at 1915 with a diagnosis of major depressive disorder and suicidal ideation (thoughts). Review of the medical record revealed documentation of individual problem sheets but failed to reveal documentation of an interdisciplinary MTP during Pt #13's admission (20 days). Review revealed treatment plan problem sheets were documented on 10/31/2023 with no time noted (4 days after admission). Review of the problem sheets revealed no documentation of updates or progress toward goals. Pt #13 was discharged home on 11/16/2023 at 1220. Review of the treatment plan problem sheets revealed no documentation of the date Pt #27's goals were achieved or discontinued.

Interview on 09/17/2024 at 1020 with Director#1 revealed the treatment plan should be updated by the Interdisciplinary Treatment Team at least every 7 days during the patient's admission. The interview revealed the update should be documented on a form titled "Master Treatment Plan Update/Clinical Staffing Worksheet." Director #1 revealed the expectation that each short-term goal on the treatment plan problem sheets should have documentation of the date the goal was achieved. The interview revealed if a goal was not achieved, there should be a note documented.

Follow-up interview on 09/20/2024 at 1335 with Director #1 revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team.

20. Closed medical record review on 09/17/2024 for Pt #66 revealed a 16-year-old female admitted to the facility on 11/14/2023 at 0958 with a diagnosis of major depressive disorder and suicidal ideation. Review of the interdisciplinary MTP, documented on 11/14/2023, revealed no documentation of patient assets, discharge criteria, or patient participation. Review revealed the MTP was not signed by the patient or patient representative. Review of the medical record revealed no documented updates to the MTP during Pt #66's admission to the facility (8 days). Pt #66 was discharged home on 11/22/2023 at 1736. Review of the medical treatment plan problem sheet "Problem: Restrictive Intervention ..." revealed no documentation of the date Pt #66's goals were achieved or discontinued.

Interview on 09/17/2024 at 1020 with Director#1 revealed the treatment plan should be updated by the Interdisciplinary Treatment Team at least every 7 days during the patient's admission. The interview revealed the update should be documented on a form titled "Master Treatment Plan Update/Clinical Staffing Worksheet."

Follow-up interview on 09/20/2024 at 1335 with Director#1 revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team. The interview revealed the MTP should be signed by everyone who participated in the development of the treatment plan, including the patient.

21. Closed medical record review on 09/11/2024 for Pt #17 revealed a 16-year-old female admitted to the facility on 10/21/2023 at 1900 with a diagnosis of major depressive disorder and suicidal ideation. Review of the interdisciplinary MTP, documented on 10/23/2023, revealed no documentation of patient assets or discharge criteria. Review revealed no documented updates to the MTP during Pt #17's admission to the facility (20 days). Pt #17 was discharged to a psychiatric residential treatment facility on 11/10/2023 at 2031. Review of the treatment plan problem sheets revealed no documentation of the date Pt #17's goals were achieved or discontinued.

Interview on 09/17/2024 at 1020 with Director#1 revealed the treatment plan should be updated by the Interdisciplinary Treatment Team at least every 7 days during the patient's admission. The interview revealed the update should be documented on a form titled "Master Treatment Plan Update/Clinical Staffing Worksheet." Director #1 revealed the expectation that each short-term goal on the treatment plan problem sheets should have documentation of the date the goal was achieved. The interview revealed if a goal was not achieved, there should be a note documented.

Follow-up interview on 09/20/2024 at 1335 with Director #1 revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team.

22. Closed medical record review on 09/10/2024 for Pt #11 revealed a 15-year-old female admitted to the facility on 10/15/2023 at 0909 with a diagnosis of major depressive disorder. Review of the medical record revealed the interdisciplinary MTP was initiated on 10/15/2023. Review of the Master Treatment Plan Update/Clinical Staffing Worksheet, on 11/20/2023, revealed documentation of a nursing update. Review revealed no documented update by the Psychiatrist or the Social Worker, no documentation of progress toward goals, and was not signed by members of the treatment team. Review of the medical record failed to reveal documented updates to the MTP by the Interdisciplinary Treatment Team during Pt #11's admission to the facility (37 days). Pt #11 was discharged to a psychiatric residential treatment facility on 11/21/2023 at 1359. Review of the medical treatment plan problem sheets "A ... Problem: Special Diet ..." and "B ... Problem: Impaired skin integrity" revealed no documentation of the date Pt #11's goals were achieved or discontinued.

Interview on 09/17/2024 at 1020 with Director #1 revealed the treatment plan should be updated by the Interdisciplinary Treatment Team at least every 7 days during the patient's admission. The interview revealed the update should be documented on a form titled "Master Treatment Plan Update/Clinical Staffing Worksheet." Director#1 stated the expectation was that the form was brought to the treatment team meeting, the update was documented during the meeting, and all members of the treatment team should sign the update. Director#1 revealed the expectation that each short-term goal on the treatment plan problem sheets should have documentation of the date the goal was achieved. The interview revealed if a goal was not achieved, there should be a note documented.

23. Closed medical record review on 09/11/2024 for Pt #16 revealed a 16-year-old female admitted to the facility on 10/19/2023 at 1913 with a diagnosis of major depressive disorder and suicidal ideation. Review of the medical record revealed the interdisciplinary MTP was initiated on 10/19/2023. Review of the Master Treatment Plan Update/Clinical Staffing Worksheet, on 11/16/2023, revealed documentation of a nursing update. Review revealed no documented update by the Psychiatrist or the Social Worker, no documentation of progress toward goals, and was not signed by members of the treatment team. Review of the medical record failed to reveal documented updates to the MTP by the Interdisciplinary Treatment Team during Pt #16's admission to the facility (29 days). Pt #16 was discharged home on 11/17/2023 at 1302. Review of the treatment plan problem sheets revealed no documentation of the date Pt#16's goals were achie

Based on a review of facility policy, medical records reviews, and staff interview, the facility staff failed to document a substantiated diagnosis on the master treatment plan within (72) seventy-two hours of admission for 4 of 82 sampled patients reviewed (Patient #3, Patient #7, Patient #13, and Patient #66).

The findings include:

Review on 09/20/2024 of facility policy "Interdisciplinary Patient-Centered Care Planning - Acute," last reviewed 03/06/2023, revealed, "... Each patient's written Treatment Plan must include: ... Substantiated diagnosis(es) ... "

1. Closed medical record review on 09/11/2024 for Patient #3 revealed a 13-year-old male admitted to the facility on 07/18/2024 under IVC for aggressive behavior was discharged on 07/31/2024. There was no psychiatric diagnosis listed on the Interdisciplinary Master Treatment Plan (MTP).

Interview on 09/20/2024 at 1335 with the Director#1 revealed the MTP should include a psychiatric diagnosis. Interview revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team. Interview revealed a psychiatric diagnosis should be documented on the MTP.



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2. Closed medical record review of Patient #7 revealed a 13-year-old male involuntarily committed on 05/20/2024 for homicidal ideation. Record review revealed the patient was discharged home on 05/24/2024. Review of the MTP dated 05/22/2024 revealed the MTP had no psychiatric diagnosis or problems listed as per the facility policy.

Interview on 09/12/2024 at 1140 with Director #6 revealed the MTP should be completed within 72 hours by the treatment team and should include a substantiated diagnosis.



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3. Closed medical record review on 09/10/2024 for Pt #13 revealed a 12-year-old female admitted to the facility on 10/27/2023 at 1915 with a diagnosis of major depressive disorder and suicidal ideation (thoughts). Review of the medical record revealed documentation of individual problem sheets but failed to reveal documentation of an interdisciplinary MTP (Master Treatment Plan) during Pt #13's admission (20 days). Review revealed treatment plan problem sheets were documented on 10/31/2023 with no time noted (4 days after admission). Review of the problem sheets failed to reveal documentation of a psychiatric diagnosis. Pt #13 was discharged home on 11/16/2023 at 1220.

Interview on 09/20/2024 at 1335 with Director #1 revealed the MTP should include a psychiatric diagnosis. Interview revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team. Interview revealed a psychiatric diagnosis should be documented on the MTP.

4. Closed medical record review on 09/17/2024 for Pt #66 revealed a 16-year-old female admitted to the facility on 11/14/2023 at 0958 with a diagnosis of major depressive disorder and suicidal ideation. Review of the interdisciplinary MTP, documented on 11/14/2023, revealed the psychiatric diagnosis was documented as "Psych eval (psychiatric evaluation) not provided to clinical staff." Review of the MTP failed to reveal documentation of a psychiatric diagnosis. Pt #66 was discharged home on 11/22/2023 at 1736.

Interview on 09/20/2024 at 1335 with Director #1 revealed the MTP should include a psychiatric diagnosis. Interview revealed the MTP should be completed within 72 hours of admission by the Interdisciplinary Treatment Team. Interview revealed a psychiatric diagnosis should be documented on the MTP. Director#1 stated "psych eval not provided to clinical staff" should not have been documented on the MTP. Interview revealed the process should have been to notify the provider immediately and obtain the necessary documentation.

Based on a review of facility policy, medical records reviews, and staff interview, the facility staff failed to document members of the interdisciplinary team on the master treatment plan for 20 of 82 sampled patients reviewed (#21, #37, #1, #3, #20, #19, #38, #45, #8, #13, #62, #63, #66, #51, #72, #53, #5, #68, #69, #67).

The findings included:

Review on 09/20/2024 of facility policy "Interdisciplinary Patient-Centered Care Planning - Acute," last reviewed 03/06/2023, revealed, "... Each patient's written Treatment Plan must include: ... The responsibilities of each member of the treatment team ... "

Review on 09/20/2024 of facility policy "Multidisciplinary Documentation and Assessment Standards," last reviewed 07/14/2021, revealed, "... Each entry must be authenticated by the full date and time as well as the full first and last name and title of credentials of the person making the entry ... Master Treatment Plan ... Responsible Person ... Therapist/Acute Clinician, RN (nurse), Physician, Adjunctive Therapy ..."

1. Closed medical record review on 09/13/2024 for Pt #21 revealed a 14-year-old male admitted to the facility on 07/17/2024 under IVC for suicidal ideation with a plan and discharged on 07/26/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 07/20/2024. The MTP failed to include documentation of the Psychiatrist signature/involvement and the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

2. Open medical record review on 09/11/2024 for Pt #37 revealed a 14-year-old male admitted to the facility on 09/01/2024 under IVC for suicidal ideation attempt. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 09/03/2024, the Nurse Practitioner was "via zoom" dated 09/03/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

3. Closed medical record review on 09/10/2024 for Pt #1 revealed an 15-year-old male admitted to the facility on 07/19/2024 under IVC for suicidal ideation attempts and eloped from Hospital B on 07/24/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Therapist on 07/22/2024, the Psychiatrist was "via zoom" dated 07/23/2024, the Nurse Practitioner was "via zoom" dated 07/23/2024 and Patient #1 signed on 07/22/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

4. Closed medical record review on 09/11/2024 for Pt #3 revealed a 13-year-old male admitted to the facility on 07/18/2024 under IVC for aggressive behavior was discharged on 07/31/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 07/22/2024, the Psychiatrist was "via telehealth" and was signed by Pt #3 on 07/22/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

5. Closed medical record review on 09/13/2024 for Pt #20 revealed a 12-year-old male admitted to the facility on 07/10/2024 under IVC for aggressiveness and was discharged on 07/24/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 07/11/2024, the Psychiatrist was "via zoom", the Nurse Practitioner was "via zoom" and was not signed by Pt #20, however dated 07/12/2024 at 1705. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

6. Closed medical record review on 09/13/2024 for Pt #19 revealed a 17-year-old male admitted to the facility on 06/14/2024 under IVC for aggressiveness and was discharged on 08/15/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 06/18/2024, the Psychiatrist was "via zoom", the Nurse Practitioner was "via zoom" and was signed by Pt #19 on 06/18/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

7. Closed medical record review on 09/13/2024 for Pt #38 revealed a 13-year-old male admitted to the facility on 06/09/2024 under IVC for not taking his medications and was discharged on 06/11/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Acute Clinician/Therapist on 06/11/2024, the Psychiatrist was "via telehealth", the Nurse Practitioner was "via zoom" and was signed by Pt #38 on 06/11/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

8. Closed medical record review on 09/17/2024 for Pt #45 revealed an 66-year-old female admitted to the facility on 05/24/2024 under IVC with a diagnosis of "Bipolar disorder, current episode, manic without psychotic features" and was discharged on 06/04/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Therapist on 05/27/2024, the Psychiatrist was "via telehealth", and Patient #45 refused to sign on 05/27/2024. The MTP failed to include documentation of the Nurse signature.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.



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9. Closed medical record review of Patient #8 revealed a 13-year-old male involuntarily committed on 05/16/2024 for suicidal ideation. Record review revealed the patient was discharged home on 05/30/2024. Review of the MTP revealed an initial date of 05/17/2024 and an updated MTP dated 05/23/2024. Review of the updated MTP revealed no printed names or signatures of any member of the treatment team and no patient/guardian signature was documented.

Interview on 09/12/2024 at 1140 with Director #6 revealed the MTP should be completed within 72 hours by the treatment team.



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10. Closed medical record review on 09/10/2024 for Pt #13 revealed a 12-year-old female admitted to the facility on 10/27/2023 at 1915 with a diagnosis of major depressive disorder and suicidal ideation (thoughts). Review of the medical record revealed documentation of individual problem sheets but failed to reveal documentation of an interdisciplinary MTP (Master Treatment Plan) during Pt #13's admission (20 days). Review revealed treatment plan problem sheets were documented on 10/31/2023 with no time noted (4 days after admission). Review of the problem sheets failed to reveal documentation/signatures of members of the interdisciplinary team. Pt #13 was discharged home on 11/16/2023 at 1220.

Interview on 09/20/2024 at 1335 with Director #1 revealed the provider, clinician, and RN were required to attend interdisciplinary treatment team meetings. Interview revealed all members of the interdisciplinary team should have signed the treatment plan.

11. Closed medical record review on 09/17/2024 for Pt #62 revealed an 11-year-old female admitted to the facility on 10/13/2023 at 1020 with a diagnosis of disruptive mood dysregulation disorder and suicidal ideation. Review of the interdisciplinary MTP, initiated on 10/16/2023, failed to reveal documentation/signatures for the Psychiatrist and the RN. Pt #62 was discharged home on 10/19/2023 at 1500.

Interview on 09/20/2024 at 1335 with Director #1 revealed the provider, clinician, and RN were required to attend interdisciplinary treatment team meetings. Interview revealed all members of the interdisciplinary team should have signed the treatment plan.

12. Closed medical record review on 09/17/2024 for Pt #63 revealed a 9-year-old male admitted to the facility on 10/12/2023 at 1834 with a diagnosis of disruptive mood dysregulation disorder (persistently angry mood and frequent temper outbursts). Review of the interdisciplinary MTP, initiated on 10/13/2023, failed to reveal documentation/signatures for the Psychiatrist and the RN. Pt #63 was discharged home on 11/08/2023 at 1240.

Interview on 09/20/2024 at 1335 with Director #1 revealed the provider, clinician, and RN were required to attend interdisciplinary treatment team meetings. Interview revealed all members of the interdisciplinary team should have signed the treatment plan.

13. Closed medical record review on 09/17/2024 for Pt #66 revealed a 16-year-old female admitted to the facility on 11/14/2023 at 0958 with a diagnosis of major depressive disorder and suicidal ideation. Review of the interdisciplinary MTP, documented on 11/14/2023, failed to reveal documentation/signature for the Acute Clinician/Therapist. Pt #66 was discharged home on 11/22/2023 at 1736.

Interview on 09/20/2024 at 1335 with Director #1 revealed the provider, clinician, and RN were required to attend interdisciplinary treatment team meetings. Interview revealed all members of the interdisciplinary team should have signed the treatment plan.




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14 . A closed medical record review for Patient #51 revealed a 22-year-old female admitted to the facility on 12/10/2023 under an IVC order for suicidal ideation with history of schizoaffective disorder, bipolar type and borderline personality disorder. Review of the MTP revealed an initial date of 12/12/2023. Review of the MTP revealed no signature by pt #51 was documented. The patient was discharged on 12/13/2023.

Interview on 09/19/2024 at 1220 with RN #19 confirmed that pt #51 did not sign the MTP.

15. A closed medical record for Patient #72 revealed a 19-year-old female admitted to the facility on 12/06/2023 under an IVC order for suicidal ideation with a plan to overdose with the diagnosis of Major Depressive Disorder (MDD). Review of the MTP revealed an initial date of 12/08/2023. Review of the MTP revealed no signature by pt #72 was documented. The patient was discharged on 12/12/2023.

Interview on 09/19/2024 at 1220 with RN #19 confirmed that pt #72 did not sign the MTP.

16. A closed medical record for Patient #53 revealed a 13-year-old female admitted to the facility on 06/17/2023 under an IVC order for suicidal ideations with a diagnosis of bipolar disorder. Review of the MTP revealed an initial date of 06/19/2023. Review of the MTP revealed it was not signed by the patient or guardian. The patient was discharged on 06/30/2023.

Interview on 09/19/2024 at 1220 with RN #19 confirmed that pt #53 the MTP was not signed by the patient or guardian.



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17. Closed medical record review on 09/10/2024 revealed Patient #5 was a 9 year old male involuntary committed to the facility on 06/14/2024 at 1155 and discharged on 06/28/2024 at 1559. The patient ws admitted with diagnosis of Schizophrenia, Unspecified and suicide ideations (SI). Review of the "Interdisciplinary Master Treatment Plan" dated 06/17/2024 revealed Patient #5's psychiatric problems included Depression with Self-Injurious Behavior and Psychosis. The medical problems included Allergies - Wheezing, GERD (acide reflux disease), Hypertension, Glucose Control, Vitamin D Deficiency and Conjunctivitis. Continued review revealed the physician and the therapist were the only signatures noted as part of Interdisciplinary Treatment Team Members.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

18. Closed medical record review on 09/17/2024 revealed Patient #68 was a 13 year old female involuntary committed to the facility on 05/30/2024 at 1604 and discharged on 08/10/2024 at 1211. The patient was admitted with diagnosis of adjustment disorder with mixed disturbance, suicide ideations (SI) and Homicidial Ideations (HI). Review of the "Interdisciplinary Master Treatment Plan" dated 05/30/2024 revealed Patient #68's psychiatric problems included Psychosis, Sexual Aggression and post traumatic stress disorder (PTSD). The medical problems included Allergies, GERD, Constipation, and Potential Fall due to Pseudo-Seizure. Continued review revealed AC #40 was the only signature noted as part of Interdisciplinary Treatment Team Members.

Interview on 09/18/2024 at 1540 with AC (Acute Clinician) #40 revealed AC #40 reviewed the Interdisciplinary Treatment Plan (IDTP) and confirmed the signatures for the responsible staff was not present and the IDTP should have been signed.

19. Closed medical record review on 09/19/2024 for Patient #69 revealed a 14 year old female patient was involuntary committed to the facility on 06/26/2024 at 2156 and discharged on 07/02/2024 at 1010. The patient was admitted with a diagnosis of Adjustment Disorder with mixed disturbance, suicide ideations (SI) and auditory hallucinations (AH). Review of the "Interdisciplinary Master Treatment Plan" dated 06/27/2024 revealed Patient #67 psychiatric diagnosis was major depressive disorder and the Psychiatric problem was suicide ideations. Review revealed the Nurse and Recreational Therapist signatures were missing from the Interdisciplinary Treatment Team Member section.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

20. Closed medical record review on 09/20/2024 for Patient #67 revealed a 9 year old male patient involuntary committed to the facility on 06/03/2024 at 1103 and discharged on 06/142024 at 2005. Patient was admitted with a diagnosis of Adjustment Disorder with mixed disturbance, suicide ideations (SI) and auditory hallucinations (AH). Review of the "Interdisciplinary Master Treatment Plan" dated 06/04/2024 revealed Patient #67 psychiatric problems included SI, Self-Injurious Behavior and Aggression. The medical problems included Allergies - Peanut, Asthma. Continued review revealed the Recreational Therapist signature was missing from the Interdisciplinary Treatment Team Member section.

Interview on 09/18/2024 at 1500 with Director #1 revealed everyone should be signing the Master Treatment Plan (MTP). There should be a Nurse Practitioner, Physician Assistant or a Psychiatrist. The patient and/or family member should be included in the MTP discussions when possible. It is the expectation that everyone sign including the nurse. The MTP should be updated every seven days and the update should be signed by the Psychiatrist, Nurse Practitioner, or Physician Assistant, then Therapist/Social Worker, and the Nurse.

Based on facility policy review, medical record review and interview, the facility staff failed to document active treatments daily for 8 of 82 patient records reviewed (Pt. #78, #80, #79, #77, #44, #75, #76 and #74).

The findings included:

Review on 09/18/2024 of the facility policy titled "Active and Individualized Treatment - Acute" approved 03/23/2023 revealed "... Definition: ... A variety of therapeutic and activity/recreational activities are used as therapeutic interventions in providing active treatment to patients. Active treatment activities include...individual, family, group therapies... Policy: ... Active treatment services provided must be: *Provided 7 days per week. ... Procedure: ... 8. Staff assigned to perform individual interventions with the patient will document these interventions in the medical record..."

1. Review on 09/20/2024 of the medical record for Patient #78 revealed a 17-year-old female admitted to the facility on 06/21/2024 at 1632 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed no documentation of recreational group therapy notes on 06/22/2024. Record review revealed no documentation of group therapy notes on 06/25/2024. The medical record review failed to reveal documentation of why Patient #78 was not provided recreational group therapy on 06/22/2024 and group therapy on 06/25/2024. Patient #78 was discharged on 06/28/2024 at 1355.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy note and group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

2. Review on 09/20/2024 of the medical record for Patient #80 revealed a 27-year-old male admitted to the facility on 06/20/2024 at 1650 with a diagnosis of Schizophrenia. Review of the medical record revealed no documentation of recreational group therapy notes on 06/22/2024. Record review revealed no documentation of group therapy notes on 06/24/2024 and 06/25/2024. Record review revealed no documentation of nursing group therapy notes on 06/21/2024. The medical record review failed to reveal documentation of why Patient #80 was not provided recreational group therapy on 06/22/2024, group therapy on 06/24/2024 and 06/25/2024 and nursing group therapy on 06/21/2024. Patient #80 was discharged on 06/27/2024 at 1140.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes, group therapy notes and nursing group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

3. Review on 09/20/2024 of the medical record for Patient #79 revealed a 38-year-old female admitted to the facility on 06/19/2024 at 2004 with a diagnosis of Paranoid Schizophrenia. Review of the medical record revealed no documentation of recreational group therapy notes on 06/22/2024. Record review revealed no documentation of group therapy notes on 06/22/2024 and 06/26/2024. Record review revealed no documentation of nursing group therapy notes on 06/21/2024, 06/22/2024, 06/23/2024, 06/24/2024, 06/25/2024 and 06/26/2024. The medical record review failed to reveal documentation of why Patient #79 was not provided recreational group therapy on 06/22/2024, group therapy on 06/22/2024 and 06/26/2024 and nursing group therapy on 06/21/2024, 06/22/2024, 06/23/2024, 06/24/2024, 06/25/2024 and 06/26/2024. Patient #79 was discharged on 06/27/2024 at 1200.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes, group therapy notes and nursing group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

4. Review on 09/20/2024 of the medical record for Patient #77 revealed a 14-year-old male admitted to the facility on 06/18/2024 at 1240 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed no documentation of recreational group therapy notes on 06/22/2024. Record review revealed no documentation of group therapy notes on 06/25/2024. The medical record review failed to reveal documentation of why Patient #77 was not provided recreational group therapy on 06/22/2024 and group therapy on 06/25/2024. Patient #77 was discharged on 06/28/2024 at 1159.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes and group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

5. Review on 09/17/2024 of the medical record for Patient #44 revealed a 23-year-old male admitted to the facility on 11/04/2023 at 1255 with a diagnosis of Major Depressive Disorder. Review of the medical record revealed no documentation of recreational group therapy notes on 11/11/2023 and 11/12/2023. Record review revealed no documentation of group therapy notes on 11/05/2023 and 11/11/2023. The medical record review failed to reveal documentation of why Patient #44 was not provided recreational group therapy on 11/11/2023 and 11/12/2023 and group therapy on 11/05/2023 and 11/11/2023. Patient #44 was discharged on 11/14/2023 at 1320.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes and group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

6. Review on 09/19/2024 of the medical record for Patient #75 revealed a 13-year-old female admitted to the facility on 10/23/2023 at 1745 with a diagnosis of Disruptive Mood Dysregulation Disorder. Review of the medical record revealed no documentation of recreational group therapy notes on 10/28/2023, 11/11/2023 and 11/12/2023. Record review revealed no documentation of group therapy notes on 10/25/2023, 10/27/2023, 11/03/2023, 11/07/2023, 11/08/2023, 11/09/2023, 11/10/2023 and 11/12/2023. The medical record review failed to reveal documentation of why Patient #75 was not provided recreational group therapy on 10/28/2023, 11/11/2023 and 11/12/2023 and group therapy on 10/25/2023, 10/27/2023, 11/03/2023, 11/07/2023, 11/08/2023, 11/09/2023, 11/10/2023 and 11/12/2023. Patient #75 was discharged on 11/13/2023 at 1422.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes and group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

7. Review on 09/19/2024 of the medical record for Patient #76 revealed a 15-year-old male admitted to the facility on 10/23/2023 at 1338 with a diagnosis of Disruptive Mood Dysregulation Disorder. Review of the medical record revealed no documentation of recreational group therapy notes on 10/28/2023. Record review revealed no documentation of group therapy notes on 10/25/2023, 10/27/2023, 10/31/2023, 11/02/2023, 11/05/2023 and 11/06/2023. Record review revealed no documentation of nursing group therapy notes on 10/28/2023, 10/31/2023 and 11/04/2023. The medical record review failed to reveal documentation of why Patient #76 was not provided recreational group therapy on 10/28/2023, group therapy on 10/25/2023, 10/27/2023, 10/31/2023, 11/02/2023, 11/05/2023 and 11/06/2023 and nursing group therapy on 10/28/2023, 10/31/2023 and 11/04/2023. Patient #76 was discharged on 11/07/2023 at 0302.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the recreational therapy notes, group therapy notes and nursing group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.

8. Review on 09/19/2024 of the medical record for Patient #74 revealed a 12-year-old female admitted to the facility on 10/15/2023 at 1234 with a diagnosis of Bipolar Disorder. Review of the medical record revealed no documentation of nursing group therapy notes on 10/24/2023. Record review revealed no documentation of group therapy notes on 10/21/2023. The medical record review failed to reveal documentation of why Patient #74 was not provided nursing group therapy on 10/24/2023 and group therapy on 10/21/2023. Patient #74 was discharged on 10/25/2023 at 1159.

Interview on 09/20/2024 at 1445 with Director #1 revealed the group, recreational and nursing therapy notes should be completed daily and on weekends.

Interview on 09/20/2024 with Director #6 revealed the staff were unable to locate the nursing group therapy notes and group therapy notes in the medical record. Interview revealed the expectation was that the staff complete the active therapy treatments daily or document individualized treatment therapy if the patients were unable to attend the group treatment sessions due to behavior, refusal, etc,.



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9. Review of a closed medical record review for Patient #52 revealed a 17-year-old male admitted to the facility on 01/19/2024 under an IVC (involuntary committment) order for suicidal ideations with a diagnosis of Major Depressive Disorder (MDD). Review of the closed medical record revealed documentation by therapy staff of a psychosocial assessement dated 01/22/2024 and three therapy (group) notes for the duration of Pt # 52's stay. Review revealed the patient was discharged on 01/31/2024 (12 day admission).

Interview on 09/19/2024 at 1210 with RN #19 confirmed that there were only 3 notes by a therapist in the closed medical record of Pt #52.

Interview with Director #6 on 09/20/2024 at 1420 confirmed that only 3 therapy (group) notes were found fot pt # 52 from 01/19/2024 through 01/31/2024.

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