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Based on record review and interview the facility failed to develop treatment plans for eight (8) of eight (8) active sample patients (A2, A15, A17, A27, B1, B3, B13, and B22) that clearly delineated physician interventions individualized to address specific problems. Specifically, the nursing staff completes the physician intervention section of the MTP by reviewing the physician orders and additionally, in seven (7) of eight (8) treatment plans there was no physician signature. This failure can result in a lack of coordination of care, and the necessary staff interventions to assist the patient in meeting their individualized goals for active treatment without direct input from the physician.

Findings include:

A. Record Review

1. Patient A2, MTP dated 1/23/2015, the physician interventions listed include: "complete history and physical", "order routine labs and other labs as necessary", and "begin medication management and make changes to medication as needed." No physician signature.

2. Patient A15, MTP dated 1/18/2016, the physician interventions listed include: "meet with client to identify diagnosis and discuss treatment regimen", order routine labs and other labs as necessary", and "begin medication management and make changes to medication as needed."

3. Patient A17, MTP dated 1/22/2016, the physician interventions listed include: "will meet with client to identify diagnosis and discuss treatment regimen", "order medical consult to address numerous and complex medical concerns", "begin medication management and make changes to medication as needed" and "order routine labs and other labs as necessary." No physician signature.

4. Patient A27, MTP dated 1/21/2016, the physician interventions listed include: "meet with client to identify diagnosis and discuss treatment regimen", "begin medication management and make changes to medication as needed", and "order routine labs and other labs as necessary. " No physician signature.

5. Patient B1, MTP dated 1/21/2016, the physician interventions listed include: "meet with client to identify diagnosis and discuss treatment regimen", "order routine labs and other labs as necessary", and "begin medication management and make changes to medication as needed." No physician signature.

6. Patient B3, MTP dated 1/22/2016, the physician interventions listed include: "complete history and physical", "assess for acute changes in mental health", and "begin medication management and make changes to medications as needed." No physician signature.

7. Patient B13, MTP dated 1/17/2016, the physician interventions listed include: "will complete history and physical", "order routine labs and other labs as necessary", and "meet with client to identify diagnosis and discuss treatment regimen." No physician signature.

8. Patient B22, MTP dated 1/21/2016, the physician interventions listed include: "will complete history and physical", "meet with client to identify diagnosis and discuss treatment regimen", "begin medication management and make changes to medication as needed." No physician signature.

B. interview

1. During an interview on 2/1/2016 at 11:25 a.m., RN1 stated that the nurses complete nursing and medical care plan section of the MTP.

2. During an interview on 2/2/2016 at 2:00 p.m., the Medical Director for Aspire Health Partners and the Medical Director for Inpatient Units confirmed the findings.




18051

Based on record review, document review and interview, the facility failed to provide complete and timely discharge summaries in accordance with hospital policy for three (3) of five (5) sample patients (C1, C2, and C3). This failure has the potential in delaying continuity of appropriate care post hospitalization.

Findings include:

B. Document Review

1. Hospital Policy titled Medical Record Standards, number 3.7.4, effective date 12/7/2015, page 4 of 6, #6. Timeliness of Entries, states, "....Records of discharged clients are to be completed as soon as possible, not to exceed 30 days outpatient and inpatient."

B. Record Review

1. Patient C1was discharged 12/26/2015. The record contained a hand written form which was not completely filled out and was not completely legible. There was no dictated summary.

2. Patient C2 was discharged 12/12/2015. The discharge summary was dictated on 1/24/2016, 34 days post discharge.

3. Patient C3 was discharged 12//24/2015. The discharge summary was dictated on 1/28/2016, 31 days post discharge.

C. Interview

1. During an interview, 2/2/2016 at 1:30 p.m., the Medical Records Supervisor confirmed the findings.

2. During an interview on 2/2/2016 at 1:40 p.m., the Vice-President of Quality and Risk Management confirmed the findings.

Based on record review and interview, the facility failed to follow their discharge record policy and provide discharge summaries containing a summary of the patient's condition at time of discharge for three (3) of five (5) sample patients (C1, C2, and C3). 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 discharged 12/26/2015. The record contained a hand written form which was not completely filled out and was not completely legible. There was no dictated summary.

2. Patient C2 was discharged 12/12/2015. The discharge summary was dictated on 1/24/2016, 34 days post discharge.

3. Patient C3 was discharged 12//24/2015. The discharge summary was dictated on 1/28/2016, 31 days post discharge.

B. Interview

1. During an interview, 2/2/2016 at 1:30 p.m., the Medical Records Supervisor confirmed the findings.

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

I. Ensure that discharge summary were completed within 30 days of discharge and contained a summary of each patient's condition at the time of discharge for three (3) of five (5) sample patients (C1, C2, and C3). This failure could potentially affect continuity of care. (Refer B133 and B135)

II. Ensure that treatment plans contained specific and individualized interventions for eight (8)of eight (8) active sample patients (A2, A15, A17, A27, B1, B3, B13, and B22). This deficient practice could lead to prolonged hospitalization and ineffective treatment. (Refer to B122)

III. Ensure that psychological services were available to hospitalized patients (56 during the survey) 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 a document review and staff interviews, 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. Document Review

1. The facility has prepared a contract for a licensed psychologist which is currently unsigned.

B. Interview

1. During an interview on 2/2/2016 at 2:00 p.m., the Medical Director for Aspire and the Medical Director for the Inpatient Units confirmed that a licensed psychologist is not in place.

2. During an interview on 2/2/2016 at 2:45 p.m., the Vice-President of Quality and Risk Management confirmed the findings.