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Based on interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment of six (6) of six (6) sample active patients (A1, A2, A3, B2, B3, B4 and B5) and discharge summaries of five (5) of five (5) discharged patients (C1, C2, C3, C4 and B5). Specifically, the hospital failed to:

I. Ensure that seven (7) of nine (9) sample patients (A1, A2, A3, B2, B3, B4 and B5) had treatment plans based on strengths and disabilities. (Refer to B119) This resulted in a lack of diagnostic information needed for the treatment team to formulate an appropriate treatment plan.

II. Ensure that seveb (7) of nine (9) sample patients (A1, A2, A3, B2, B3, B4 and B5) had treatment plans which contain individual specific and measurable long term and short term goals. This resulted in a lack of clarity and direction to the treatment plan. (Refer to B121)

III. Develop treatment plans that identified clearly delineated physician, nursing and social work interventions to address specific treatment needs for one (1) of nine (9) sample patients (B3). This resulted in treatment plans that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122 and B125)

IV. Ensure that one (1) of nine (9) sample patients (B3) had progress notes which documented therapeutic activities and measured patient progress toward goals. This resulted in lack of direction for the treatment planning process. (Refer to B127)

V. Ensure that five (5) of five (5) discharge sample patients (C1, C2, C3, C4 and C5) had discharge summaries which recapitulated the hospitalization and provided a summary of the patient's condition at time of discharge. This resulted in a lack of continuity of care. (Refer to B133 and B135)

Based on record review, document review and interview, the facility failed to identify the strengths and disabilities of each patient on which to base the treatment plan for seven (7) of nine (9) patients in the active sample (A1, A2, A3, B2, B3, B4 and B5). This resulted in treatment plans that were not comprehensive of individualized for the patient.

Findings Include:

A. Record Review

1. Patient A1, admitted 08/28/2015, Master Treatment Plan (MTP) dated, 09/01/2015 did not have documented strengths and disabilities.

2. Patient B4, admitted 09/24/2015, MTP dated 09/28/2015 did not have documented strengths and disabilities.

3. Patient B2, admitted 09/29/2015, MTP dated 10/04/2015 did not have documented strengths and disabilities.

4. Patient B3, admitted 10/03/2015, MTP dated 10/08/2015 did not have documented strengths and disabilities. Specifically the patients MTP did not identify the limited English proficiency as a barrier to treatment.

5. Patient B5, admitted 10/07/2015, MTP dated 10/12/2015did not have documented strengths and disabilities.

6. Patient A2, admitted 10/07/2015, MTP dated 10/12/2015 did not have documented strengths and disabilities.

7. Patient A3, admitted 10/07/2015, MTP dated 10/12/2015 did not have documented strengths and disabilities.

B. Document Review

Hospital policy, "Treatment planning and Modifications," effective date 10/25/1995, revision date 03/27/2009, page two (2) of five (5) states "Treatment Plan(s) refers to a written, comprehensive statement of treatment goals and measureable objectives, and includes a delineation of the type, frequency and duration of services to be provided." Procedure (section C) states "the primary care provider and other care providers involved in the client's care (treatment team) will work collaboratively with the person served in development of a treatment plan which will address; current level of functioning, identified needs, goals, discharge plan, method for providing service and time frames of accomplishment of the individual's plan of care." This policy does not state that the treatment plan would be developed taking into account the patients strengths and disabilities.


C. Interview

During an interview by both surveyors at 2:15 p.m. on 10/13/2015 the Clinical Manager for Social Work, stated "our Master Treatment Plan does not include the patients' strengths and limitations. This information is included on the multidisciplinary integrated summary for treatment/service planning form but to date this information does not transfer to the master treatment plan form. We have not built that into our process yet, that is a goal when our treatment plans become electronic on the Avatar system (electronic medical record)."

Based on a record review, document review, and interview, the facility failed to ensure that treatment plans included long-term and short-term goals that were stated in observable, measurable, and behavioral terms for seven (7) of nine (9) (A1, A2, A3, B2, B3, B4, and B5) active sample patients. Absence of observable, measurable, and behavioral goals hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review

1. Patient A1, admitted 08/28/2015, Master Treatment Plan (MTP) dated, 09/01/2015 did not identify long or short term goals.

2. Patient B4, admitted 09/24/2015, MTP dated 09/28/2015 did not identify long or short term goals.

3. Patient B2, admitted 09/29/2015, MTP dated 10/04/2015 did not identify long or short term goals.

4. Patient B3, admitted 10/03/2015, MTP dated 10/08/2015 did not identify long or short term goals.

5. Patient B5, admitted 10/07/2015, MTP dated 10/12/2015did not identify long or short term goals.

6. Patient A2, admitted 10/07/2015, MTP dated 10/12/2015 did not identify long or short term goals.

7. Patient A3, admitted 10/07/2015, MTP dated 10/12/2015 did not identify long or short term goals.


B. Document Review

Hospital Policy, "Treatment planning and Modifications," effective date 10/25/1995, revision date 03/27/2009, page two (2) of five (5) states "Treatment Plan(s) refers to a written, comprehensive statement of treatment goals and measureable objectives, and includes a delineation of the type, frequency and duration of services to be provided." Procedure (section C) states "the primary care provider and other care providers involved in the client's care (treatment team) will work collaboratively with the person served in development of a treatment plan which will address; current level of functioning, identified needs, goals, discharge plan, method for providing service and time frames of accomplishment of the individual's plan of care." This policy did not state that the treatment plan required long and short term goals.

C. Interview

1. During an interview at 2:15 p.m. on 10/13/2015 the Clinical Manager for Social Work confirmed the finding.

2. During an interview at 3:15 p.m. on 10/13/2015, the Medical Director for Aspire and the Medical Director for Inpatient Services confirmed the findings.

Based on record review, interview and document review the facility failed to develop treatment plans for one (1) of nine (9) active sample patients (B3) that clearly delineated interventions to address specific problems. Specifically, the facility failed to develop and document a treatment plan on Patient B3 for limited English proficiency and an effective means for the staff to communicate with and engage the patient in treatment. This failure resulted in a lack of coordination of care, and the necessary staff interventions to assist the patient in meeting their individualized goals for active treatment.

Findings include:

A. Record Review

1. Patient B3, admitted 10/03/2015, MTP dated 10/08/2015 did not identify the limited English proficiency as a barrier to treatment.

2. The psychosocial assessment (general) updated on 10/06/2015 by SW1 documented the following "due to Vietnamese and the primary language of client, all client information during the assessment was translated by a friend."

B. Document Review

1. Hospital Policy, "Assessment and access to auxiliary aids and services," #2.0.6, effective date 07/01/2014 and revised 09/15/2015 purpose statement "it is the policy of Aspire Health Partners, Inc. (AHP) to assess the needs and make necessary accommodations for auxiliary communication aids and services for clients who are deaf, hard of hearing, visually impaired or have limited English proficiency." The scope of this policy states: "This directive pertains to all AHP representatives in all clinical program areas in all facilities owned, leased, or operated by the company."

C. Interview

1. During an interview on 10/13/2015 at 2:15 p.m., the Clinical Manager for Social Work confirmed the findings.

2. During an interview on 10/13/2015 at 3:15 p.m., the Medical Director for Aspire Health Partners and the Medical Director for Inpatient Units confirmed the findings.

Based on observation, interview, document and record review, the facility failed to adequately assess one (1) of one (1) active sample patients with special needs, Patient B3, who has limited English proficiency due to the patients' primary language of Vietnamese. This failure results in a delay in treatment, a lack of engagement in active treatment and the potential for ineffective communication regarding treatment issues and/or concerns.

Findings include:

A. Observation

1. The surveyor attended the critical thinking group from 1:00 p.m. to 1:45 p.m., on 10/12/2015 patient B3 was in attendance. Therapist 1 provided the group members with a paper that had a total of 68 items to choose 10 selections from the list that they would want if they found themselves to be on a deserted island. Patient B3 sat on the periphery of the group, did not have a copy of the paper with the list and did not have any verbal interaction during the group and left the group at 1:38 p.m.

2. The surveyor attended the nursing group on 10/13/2015 at 10:45 a.m., the patient was sitting in a chair next to the doorway to the room not engaged in conversation with other patients. At the end of the group the surveyor asked the patient, in front of the Clinical Director for Acute Care and RN1 what she just talked about in the group, patient B3 put her hands up, shrugged her shoulders, nodded her head and stated "I don't understand." Both the Clinical Director for Acute Care and RN1 who witnessed this interaction and response agreed that due to the patient's limited English proficiency it is difficult to determine what the patient does or does not understand. The Clinical Director for Acute Care stated "I see what you mean about the concerns that treatment is not being provided."

B. Interview

1. During an interview with RN1 on 10/13/2015 at 9:30 a.m. the surveyor showed the nursing assessment summary of findings documentation note that had been completed by RN1 on 10/03/2015 at 9:39 a.m. The summary of findings note specifically had the following documentation "speech is normal with disorganized and illogical thoughts." The surveyor asked RN1 to discuss how RN1 was able to make this assessment as recorded in this progress note since the patient spoke little English, as documented in the intake notes received on the unit with the admission. RN1 stated, "I see what you mean, its' hard to say that the patient had disorganized and illogical thoughts if I don't know whether the patient understood what I was asking." Additionally, the surveyor asked RN1 how nursing staff are communicating with this patient on a daily basis and recording their interactions, RN1 stated "the patient does make her needs known to staff when asked, but I understand what you are saying we do not know what she understands or does not understand." When RN1 was specifically asked if this language barrier had been identified on the patient's treatment plan with interventions outlined for the team to have effective communication and engagement in therapeutic programming for the patient (B3), RN1 stated "I wouldn't even know where that would be documented on the patient's treatment plan."

2. The Nurse Manager for the 4E and 4West units was interviewed on 10/13/2015 at 10:20 a.m. During this interview the surveyor asked the Nurse Manager if she were aware that there was a limited English proficient patient on the 4West unit. The Nurse Manager responded that she was aware of this patient through reports received. When asked by the surveyor what her expectation was for the nurse who completed the nursing assessment on admission related to documentation and care planning for this patient (B3) who had the limited English proficiency, she stated "they have been told if they cannot communicate and there is no interpreter available immediately, they are to record their observations and to document in their summary of findings at the end of the assessment the issue with communication." The same nursing assessment and summary of finding note reviewed with RN1 documented on 10/03/2015 at 9:30 a.m. was shown to the Nurse Manager to verify whether this expectation in documentation had been met, the Nurse Manager verified that there was "no documentation by the nurse that would indicate there was a language barrier for treatment." Additionally, the surveyor asked the Nurse Manager to review the Master Treatment Plan completed for B3 on 10/08/2015 to identify where this language barrier had been incorporated, the Nurse Manager stated "there is no identification and I am not sure who should have written this or where this should have been written."

3. During an interview by both surveyors at 2:15 p.m. on 10/13/2015, the Clinical Manager for Social Work stated, "we did not recognize this as a language barrier issue until we began to look at discharge, because it was not until that time that we were unsure of whether it was a cognitive or other issue. That is why we did not have an interpreter in sooner and had the interpreter scheduled to meet with the team, the patient and the identified extended family on Monday,10/12/2015." The Clinical Manager of Social Work verified, when shown the patient's (B3) Master Treatment Plan that the issue with language being a barrier to treatment was "not included on the patient's treatment plan." The Clinical Manager of Social Work stated "I am going to need to find a way to educate staff on how to write objectives and interventions for these special needs of patients." Additionally, the Clinical Manager of Social Work also was unaware that staff had been documenting in notes that there were difficulties in providing treatment due to the patient's limited English proficiency. The following note was shown to the clinical manager for the current events group therapy note, led by the social worker, dated 10/06/2015, 1:00-1:45 p.m. which stated "client did attend group, but did not participate due to language barrier." Once reviewing this note the Clinical Manager of Social Work stated "you ' re right that is a problem."



C. Document Review

1. Hospital Policy, "Assessment and access to auxiliary aids and services," #2.0.6, effective date 07/01/2014 and revised 09/15/2015 purpose statement "it is the policy of Aspire Health Partners, Inc. (AHP) to assess the needs and make necessary accommodations for auxiliary communication aids and services for clients who are deaf, hard of hearing, visually impaired or have limited English proficiency." The scope of this policy states: "This directive pertains to all AHP representatives in all clinical program areas in all facilities owned, leased, or operated by the company."

2. Hospital Policy, "Accessibility Plan," #1341e, effective date 01/13/1993 and revised 04/29/2014, section 5(c) states "interpreters will be made available to disabled persons through our internal language band or external resources. Nationally certified interpreters may be provided in person or through Video Remote Interpretation (VRI) which meet HIPAA requirements for confidentiality. VRI interpreters are available in Spanish and English; other languages require 24 hour notice."

D. Record Review


1. The Psychiatric History and Physical Admission Evaluation completed by Physician 1 on 10/03/2015 under social/legal history has documented "patient was born and raised in Vietnam, came to US in 1992, went to school to learn English but had difficulty adjusting." Additionally, under the mental status examination section of this same evaluation has documented that "speech is with a heavy accent, difficult at times to communicate."

2. The Master Treatment Plan for patient B3, completed on 10/08/2015 did not identify the patient's limited English proficiency as a barrier to treatment. There was no problem, objectives or interventions/modalities, short or long term goals written by any member of the multidisciplinary team to address how to provide active treatment for this patient.

3. The nursing assessment completed on 10/03/2015 at 9:30 a.m. did not have limited English proficiency identified as a barrier to treatment.

4. The psychosocial assessment (general) updated on 10/06/2015 by SW1 documented the following "due to Vietnamese and the primary language of client, all client information during the assessment was translated by a friend."

5. The Music Therapy/card games group led by the Mental Health Technician, dated 10/03/2015 from 4:00 p.m. - 5:00 p.m. had documented "attended group but did not participate, just sat there and watched other clients play games." There was no indication in the documented note that the Mental Health Technician had any specific interaction with patient, B3.

6. The leisure/recreational skills activity held 10/04/2015 from 11:00 a.m. -12:00 p.m. had documented "clients were encouraged to participate in a relaxation/stress relief activity." The activity consisted of the clients singing their favorite song. After activity was complete, clients were asked to describe activities they participate in to relieve stress. The group not had documented "Client (B3) chose not to attend group, was given a handout about topic." There was no indication in the documented note that the patient received a handout in her primary language.

7. The recreational/leisure activity held 10/04/2015 from 4:15 p.m.-5:00 p.m. had documented "clients were encouraged to attend and engage in Anger Management group. Therapist tossed a beach ball around the room with anger management topics written on the balls various colored sections. Whatever topic was near their right thumb a discussion was suggested. The group note had documented, "Client (B3) did not attend- offered client information about positive affirmations." There was no indication that this information offered was provided in the patient's primary language or provided in a way that the information could be understood by the patient.

8. The nursing group, led by the RN titled, ways to keep a calm environment dated 10/05/2015 from 10:15 a.m - 11:00 a.m. had documented patient (B3) "sat quietly and listened as others spoke, refused to verbalize any suggestions." There was no indication in the documented note that the RN had any specific interaction with patient, B3.

9. The activity group, titled name 5, led by the Activity Therapist, dated 10/05/15 from 4:15 p.m - 5:00 p.m. has documented "clients were collectively asked to name five things on a specific topic. Client (B3) did not put forth any effort to partake in group activities. Instead watched everyone else participate." There was no indication in the documented note that the staff had any specific interaction with patient, B3.

10. The current events group therapy note, led by the social worker, dated 10/06/2015, 1:00 p.m. - 1:45 p.m. states "client did attend group, but did not participate due to language barrier."

11. The positive memories group note dated 10/08/2015, 1:00 p.m. - 1:45 p.m., led by the Licensed Mental Health Clinician, has documented "group discussed positive memories, patient (B3) did attend, but did not participate when prompted."

12. The obstacles and goals group, led by the social worker, note dated 10/09/2015, 1:00 -1:45 p.m. has documented "did attend, but refused to participate."

13. The goal group, led by the Mental Health technician, note dated 10/11/2015, 9:00 a.m. - 9:30 a.m. has documented "client (B3) was unable to focus and conversate." There was no indication in the documented note that the Mental Health Technician had any specific interaction with patient, B3.

Based on record review and interview, the facility failed to ensure that nurses regularly recorded in progress notes, assessments and nursing interventions utilized and their effectiveness in communicating with one (1) of one (1) active sample patients with limited English proficiency, Patient, B3. Instead the progress notes were generic and indicated the patient was either withdrawn and had minimal interactions with peers and communicated appropriately with staff upon prompting. This failure results in the patient not having a coordinated plan for how to have their needs met and therefore was not receiving active treatment.

Findings include:

A. Record Review

1. Nursing progress notes written on 10/03/2015 at 5:31 p.m. had documented "withdrawn, poor insight, minimal interactions with peers." There is no evidence documented that the nurse was able to communicate with the patient to make this assessment.

2. Nursing progress note written 10/04/2015 at 12:13 p.m. had documented "withdrawn and isolative to self on unit; little or no interactions with peers. Tangential and presents disorganized thought process." There is no evidence documented that the nurse was able to communicate with the patient to make this assessment.

3. Nursing progress note written 10/05/2015 at 7:29 p.m. had documented "isolated at times, limited interaction with peers. Appears to not be processing very well as patient has to be told something a couple of times before patient understands." There is no evidence that the nurse was able to effectively communicate with the patient in a way that the patient could understand.

4. Nursing progress note written on 10/06/2015 at 10:35 a.m. had documented " withdrawn and isolative to self; minimal interactions with peers as client is selectively social; unable to stay on topic as client is tangential. " There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand.

5. Nursing progress note written on 10/06/2015 at 10:25 p.m. had documented " withdrawn, pacing, isolative to self, minimal interactions to peers and staff. " There is no evidence documented that the nursing staff attempted to communicate with the patient.

6. Nursing progress note written on 10/08/2015 at 8:29 p.m. had documented " poor insight and has a hard time understanding when staff answers the patients questions. " There is no evidence documented that the nursing staff identified that the patient ' s language barrier impedes the patient ' s ability to understand the English language.

7. Nursing progress note written on 10/09/2015 at 9:29 a.m. had documented " Limited English speaking, withdrawn and isolative; communicates when prompted. " There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand.

8. Nursing progress note written on 10/10/2015 at 2:04 p.m. had documented " speech is disorganized and tangential thoughts and content; has poor insight and judgment; is withdrawn to self. " There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand to make this assessment of mental status.

B. Interview

During the interview with the Nurse Manager on 10/13/2015 at 10:00 a.m. she stated " nothing has been put in place by nursing to demonstrate and ensure that they are able to communicate effectively with this patient or to assure that their assessment findings are being documented accurately. You are correct, we cannot verify in these notes (when the above dated progress notes were reviewed) that the patient was able to understand what was being asked because of the patient ' s limited English. "

Based on record review, document review and interview, the facility failed to provide complete and timely discharge summaries in accordance with hospital policy for five (5) of five (5) sample patients (C1, C2, C3, C4 and C5). This failure has the potential in delaying continuity of appropriate care post hospitalization.

Findings include:

A. Record Review

1. Patient C1was admitted 10/2/2015 and discharged 10/5/2015. The record did not contain a completed discharge summary as of 10/13/2015.

2. Patient C2 was admitted 9/25/2015 and discharged 10/2/2015. The record did not contain a completed discharge summary as of 10/13/2015.

3. Patient C3 was admitted 9/16/2015 and discharged 10/5/2015. The record did not contain a completed discharge summary as of 10/13/2015.

4. Patient C4 was admitted 9/29/2015 and discharged 10/5/2015. The record did not contain a completed discharge summary as of 10/13/2015.

5. Patient C5 was admitted 9/25/2015 and discharged 10/2/2015. The record did not contain a completed discharge summary as of 10/13/2015.

B. Document Review

1. Hospital Policy titled Medical Record Standards, number 2101d, revised 12/5/2013, page 5 of 7, #6. Timeliness of Entries, states, "....Records of discharged clients are to be completed as soon as possible, not to exceed 30 days outpatient and 7 days inpatient."

B. Interview

1. During an interview, 10/13/2015 at 10:23 a.m., the Medical Records Supervisor confirmed the findings.

2. During an interview on 10/13/2015 at 3:15 p.m., the Medical Director for Aspire and the Medical Director for the Inpatient Units confirmed the findings.

Based on record review and interview, the facility failed to provide discharge summaries containing a summary of the patient's condition at time of discharge for five (5) of five (5) sample patients (C1, C2, C3, C4 and C5). This failure could result in patients not receiving appropriate aftercare due to insufficient information in the transition of care.

Findings include:

A. Record Review

1. Patient C1was admitted 10/2/2015 and discharged 10/5/2015. The record did not contain a summary of the patient's condition on discharge as of 10/13/2015.

2. Patient C2 was admitted 9/25/2015 and discharged 10/2/2015. The record did not contain a summary of the patient's condition on discharge as of 10/13/2015.

3. Patient C3 was admitted 9/16/2015 and discharged 10/5/2015. The record did not contain a summary of the patient's condition on discharge as of 10/13/2015.

4. Patient C4 was admitted 9/29/2015 and discharged 10/5/2015. The record did not contain a summary of the patient's condition on discharge as of 10/13/2015.

5. Patient C5 was admitted 9/25/2015 and discharged 10/2/2015. The record did not contain a summary of the patient's condition on dischargeas of 10/13/2015.

B. Interview

1. During an interview on 10/13/2015 at 3:15 p.m., the Medical Director for Aspire and the Medical Director for the Inpatient Units, confirmed the findings.

Based on record review and interview, the Medical Director failed to:

I. Ensure that discharge summary were completed within 7 days of discharge and contained a summary of each patient's condition at the time of discharge for five (5) of five (5) sample patients (C1, C2, C3, C4, and C5). This failure could potentially affect continuity of care. (Refer B133 and B135)

II. Ensure that treatment plans contained, long and short-term goals, specific and individualized interventions for seven (7) of nine (9) active sample patients (A1, A2, A3, A4, A5, and A6). This deficient practice could lead to prolonged hospitalization and ineffective treatment. (Refer to B121 and B122)

III. Ensure that active treatment was available to patients with limited proficiency in English for one (1) of nine (9) active sample patients (B3). This deficient practice fails to provide psychiatric leadership to the treatment process. (Refer to B125)

IV. Ensure that psychological services were available to one (1) of nine (9) patients (B5) to aid in providing diagnostic clarity. This deficient practice could lead to delay in establishing an accurate diagnosis and prolonged hospitalization. (Refer to B151)

Based on record review, observation and interview, the Director of Nursing failed to ensure that nursing staff followed acceptable standards of practice for assessment, intervention and plan of care for one (1) of one (1) active patient's with limited English proficiency, Patient, B3. This failure results in the patient not receiving active treatment and not having their personal needs met.

Findings include:

A.Record Review

1 .The nursing assessment completed on 10/03/2015 at 9:30 a.m. did not have limited English proficiency identified as a barrier to treatment.

2. Music therapy/card game activity group note documented by Mental Health Technician on 10/03/2015 for 4:00 p.m. - 5:00 p.m. activity has documented "Patient, B3 (limited English proficiency) attended group, but did not participate-sat and watched others play games." There was no indication in the documented note that the Mental Health Technician had any specific interaction with patient, B3. Level of participation had the following areas checked, "active and refusing;" quality of participation section checked " appropriate, supportive and distracting;" insight section has both "lacks insight and good insight" checked.

3. Nursing progress notes written on 10/03/2015 at 5:31 p.m. had documented "withdrawn, poor insight, minimal interactions with peers." There is no evidence documented that the nurse was able to communicate with the patient to make this assessment.

4. Nursing progress note written 10/04/2015 at 12:13 p.m. had documented "withdrawn and isolative to self on unit; littleor no interactions with peers. Tangential and presents disorganized thought process." There is no evidence documented that the nurse was able to communicate with the patient to make this assessment.

5. The nursing group, led by the RN titled, ways to keep a calm environment dated 10/05/2015 from 10:15 a.m - 11:00 a.m. had documented patient (B3) "sat quietly and listened as others spoke, refused to verbalize any suggestions." There was no indication in the documented note that the RN had any specific interaction with patient, B3.

6. Nursing progress note written 10/05/2015 at 7:29 p.m. had documented "isolated at times, limited interaction with peers. Appears to not be processing very well as patient has to be told something a couple of times before patient understands." There is no evidence that the nurse was able to effectively communicate with the patient in a way that the patient could understand.

7. Nursing progress note written on 10/06/2015 at 10:35 a.m. had documented "withdrawn and isolative to self; minimal interactions with peers as client is selectively social; unable to stay on topic as client is tangential." There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand.

8. Nursing progress note written on 10/06/2015 at 10:25 p.m. had documented "withdrawn, pacing, isolative to self, minimal interactions to peers and staff." There is no evidence documented that the nursing staff attempted to communicate with the patient.

9. Nursing progress note written on 10/08/2015 at 8:29 p.m. had documented "poor insight and has a hard time understanding when staff answers the patients questions." There is no evidence documented that the nursing staff identified that the patient's language barrier impedes the patient's ability to understand the English language.

10. Nursing progress note written on 10/09/2015 at 9:29 a.m. had documented "Limited English speaking, withdrawn and isolative; communicates when prompted." There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand.

11. Nursing progress note written on 10/10/2015 at 2:04 p.m. had documented "speech is disorganized and tangential thoughts and content; has poor insight and judgment; is withdrawn to self." There is no evidence documented that the nurse was able to communicate with the patient in a way that the patient could understand to make this assessment of mental status.

12. Goal group note documented by Mental Health Technicianon 10/11/2015 for 9:00-9:30 a. m. group has documented "client (Patient, B3) was unable to focus and conversate." There was no indication in the documented note that the Mental Health Technician had any specific interaction with patient, B3.

B. Interview

1. During interview with the Nurse Manager on 10/13/2015 at 10:00 a.m. she reviewed the nursing progress notes and group therapy notes written by the Mental Health Technicians and stated "I understand what you are saying, these do not show that nursing is able to adequately communicate with this patient (B3). I also understand, why you are saying there is discrepancies in the documentation by the Mental Health Technician in the note you have shown me because of the way they have checked items in the different sections." The Nurse Manager stated, "I see what you mean that the Mental Health Technician group notes are not being reviewed by the nurse on the shift." The Nurse Manager also verified that there were no communication needs identified as part of the nursing assessment and summary of findings done on admission and that there were no interventions listed on the patients Master Treatment Plan directing the nursing staff on how to interact with this patient.

2. During an interview with the Vice President of Nursing, the Director of Nursing and the Nurse Manager on 10/13/2015 at 3:15 p.m. based on the information reviewed related to nursing assessments, progress notes and group documentation on the record of Patient, B3 they all agreed that "interventions should have been put into place by nursing to ensure that appropriate and adequate communication was occurring with this patient. We have access to the VRI (video remote interpretation) on the units, we also have a nurse and physician in our CRC that speak fluent Vietnamese that we could have made arrangements to provide this service."

Based on a record review and staff interviews, the hospital failed to provide the services of a licensed Psychologist to address the needs of one (1) of nine (9) active sample patients (B5). In addition, the facility did not provide any assessments or interventions by a licensed Psychologist for any patients in its care over the past 365 days. This deficiency potentially results in patients not receiving a full array of diagnostic and interventional services, and can cause uncoordinated care and protracted hospital stays.

Findings Include

A. Record Review

1. Patient B5 was admitted 10/7/2015 with diagnoses of Unspecified Psychotic Disorder, rule out Schizoaffective Disorder, Diabetes Mellitus and Limited Social Support. The assessment lists cognitive deficits among an inventory of weaknesses; however, did not request psychological or neurological assessments to help clarify the diagnoses and aid in treatment planning.

B. Interview

1. During an interview with the Director for Quality Improvement on 10/12/2015 at 11:30 a.m., the findings were confirmed.

2. During an interview on 10/13/2015 at 3:15 p.m., the Medical Director for Aspire and the Medical Director for the Inpatient Units confirmed the findings.

Based on record review and interview, the Clinical Manager for Social Work failed to adequately monitor and evaluate the quality of social services and documentation for one (1) of nine (9) patients (B3). This failure resulted in prolonged hospitalization without receiving appropriate interpreter services for limited proficiency in English.

Findings include


A. Record Review

1. The current events group therapy note, led by the social worker, dated 10/06/2015, 1:00 p.m. - 1:45 p.m. states "client did attend group, but did not participate due to language barrier."

2. The positive memories group note dated 10/08/2015, 1:00 p.m. - 1:45 p.m., led by the Licensed Mental Health Clinician, has documented "group discussed positive memories, patient (B3) did attend, but did not participate when prompted."

3. The obstacles and goals group, led by the social worker, note date 10/09/2015, 1:00 p.m. - 1:45 p.m. has documented "did attend, but refused to participate."

B. Interview

1. During an, with the Clinical Manager of Social Work on 10/13/2015 at 2:15 p.m. she state she was unaware that staff had been documenting in notes that there were difficulties in providing treatment due to the patient's limited English proficiency. The current event note written by the social worker, dated 10/06/2015, 1:00 p.m. - 1:45 p.m. which stated "client did attend group, but did not participate due to language barrier" was shown to the Clinical Manager of Social Work. Once reviewing this note the Clinical Manager of Social Work stated "you're right that is a problem."