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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 treatment for 8 of 8 sample active patients (A, B, C, D, E, F and G). Specifically the facility failed to:

I. Complete Psychosocial Assessments for 2 of 8 active sample patients (E and H). This deficient practice results in the multidisciplinary treatment team not having psychosocial data to use for treatment planning, potentially compromising effective treatment of patients. (Refer to B108)

II. Ensure that the Psychiatric Evaluations for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) described the patient's memory functioning with supportive information. Failure to document memory testing with the methods of the testing used compromises the identification of pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. Provide Master Treatment Plans for 7 of 8 active sample patients (A, B, C, D, E and F) that were based on assessments of the patients' strength and disabilities. This deficiency results in treatment plans that are not comprehensive or individualized, potentially compromising the effectiveness of treatment. (Refer to B119)

IV. Develop Master Treatment Plans that clearly identified interventions by physicians, nurses, social workers, mental health therapy aides, and Activity Therapists to address the individual needs of 8 of 8 active sample patients (A, B, C, D, E, F, G and H). The treatment plan interventions were preprinted, routine, generic discipline functions that lacked a specific focus. This deficiency hampers staffs ability to provide comprehensive, integrated and individualized treatment to patients. (Refer to B122)

Based on record review and interview, the social service assessments for 2 of 8 active sample patients (E and H) were not completed. This deficiency results in the treatment team not having available baseline social assessment data that can be used to establish treatment goals and interventions for patients.

Findings include:

A. Record Review

1. Patient E was admitted on 11/12/2010. As of 11/22/2010, the social service assessment was not in the medical record. Review of the medical record revealed that the patient's mother was the legal guardian. There was no evidence that the patient's mother was contacted by the facility to obtain a psychosocial history.

2. Patient H was admitted on 11/19/2010. As of 11/23/2010, the social service assessment was not in the medical record.

B. Interview

In an interview on 11/23/2010 at 9:45AM, the Director of Quality Improvement stated that the facility's policy requires the social assessment to be done within 72 hours of admission. The Director of Quality Improvement acknowledged that the social assessments for patients E and H were missing from the medical record. The Director also stated "We are making an attempt to get history on [patient E]. Patient does not have any family member." When it was pointed out that, according to the medical record, the patient's mother was the patient's legal guardian, the Director of Quality Improvement acknowledged that the patient's mother was not contacted.

Based on record review and interview, it was determined that the hospital failed to perform and document memory functioning with supportive information for 8 of 8 active sample patients (A, B, C, D, E, F, G and H). Failure to document the methods of memory testing compromises the identification of pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examination to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient A was admitted on 11/19/2010. The Psychiatric Evaluation of 11/20/2010 stated "recent and remote memory WNL [within normal limits]." There was no supportive information documented.

2. Patient B was admitted on 11/04/2010. The Psychiatric Evaluation of 11/04/2010 stated "recent and remote memory WNL." There was no supportive information documented.

3. Patient C was admitted on 11/19/2010. The Psychiatric Evaluation of 11/19/2010 stated "recent and remote memory WNL." There was no supportive information documented.

4. Patient D was admitted on 11/14/2010. The Psychiatric Evaluation of 11/15/2010 stated "impaired memory." There was no supportive information documented.

5. Patient E was admitted on 11/12/2010. The Psychiatric Evaluation of 11/12/2010 stated "He is not answering questions. He is in an almost catatonic state. I could not complete a mental status examination." As of 11/23/2010, there was no documentation in the medical record of further attempts to complete the mental status examination

6. Patient F was admitted on 11/17/2010. The Psychiatric Evaluation of 11/17/2010 stated "she has limited memory." There was no supportive information documented.

7. Patient G was admitted on 11/12/2010. The Psychiatric Evaluation of 11/12/2010 stated "recent and remote memory impaired." There was no supportive information documented.

8. Patient H was admitted on 11/19/2010. The psychiatric evaluation done on 11/19/2010 stated "recent and remote memory impaired." There was no supportive information documented.

B. Interview

In an interview on 11/23/2010 at 10:30AM, the Medical Director acknowledged that the psychiatric evaluations did not document supportive information justifying the conclusions about memory functioning.

Based on record review and staff interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for 5 of 8 active sample patients (A, B, D, G and H) were based on the inventory of patient's strengths and disabilities. In 2 of the 8 records, (E and F) the inventory was not sufficiently developed to be used as the basis for developing the plan. These failures compromise the effectiveness of treatment by failing to engage the patients through use of their strengths and with awareness of their disabilities.

Findings include:

A. Record Review (MTP dates in parentheses)

The MTPs included checklists to identify patient assets and stressors. Those assets and stressors identified for the 7 sample patients were as follows:

1. Patient A: The MTP (11/19/10) identified assets as "general Fund of Knowledge, Average or above intelligence, communication skills." The checked stressors were "Family conflict, educational concerns." The MTP interventions, e.g., "Patient education regarding illness to promote self-care and prevent relapse" did not specifically relate to the assets or stressors.

2. Patient B: The MTP (11/4/10) identified assets as "general fund of knowledge, motivation for treatment, religious affiliation." The checked stressors were "financial difficulties, substance abuse, medication change or non-compliance, health problems." The MTP interventions, e.g., "patient education related to effects and side effects of medication" and "Patient education regarding illness to promote self-care and prevent relapse" did not specifically relate to the assets or stressors.

3. Patient D: The MTP (11/14/10) identified assets as "general Fund of knowledge, Average or above intelligence, supportive family/friends, motivation for treatment, work skills-has job." The checked stressor was "marital or family conflict." The listed MTP interventions, e.g. "patient education related to effects and side effects of Risperdal (medication)" and "patient education regarding illness to promote self-care and prevent relapse" did not specifically relate to the assets or stressors.

4. Patient E: The MTP (11/12/10) only identified assets as "supportive family/friends." The checked stressor was "other" without any additional information.

5. Patient F: The MTP (11/17/10) identified assets as "supportive family/friends." The checked stressors were "medication change or non-compliance." The MTP intervention, "patient education regarding illness to promote self care and prevent illness" did not specifically relate to the assets or stressors.

6. Patient G: The MTP (11/13/10) identified assets as "average or above average intelligence"; "supportive family/friends"; "ability for insight" and "communication skills." The checked stressors were "substance abuse"; "medication change or non-compliance" and "health problems." The MTP interventions, "patient education related to effects and side effects of medication" and "patient education regarding illness to promote self care and prevent relapse" did not specifically relate to the assets or stressors.

7. Patient H: The MTP (11/19/10) identified assets "general fund of knowledge"; "average or above average intelligence"; "supportive family"; and "ability for insight." The checked stressors were "substance abuse"; "medication change or noncompliance" and "marital or family conflict." The Intervention "patient education related to effects and side effects" and "patient education regarding illness to promote self care and prevent relapse" were not specifically related to the assets or stressors.


B. Staff Interview


The surveyor met with the Medical Director on 11/23/2010 at 10:30AM to discuss the failure of the facility to utilize the treatment team's assessment of assets and disabilities in the Master Treatment Plans. The Medical Director acknowledged the deficiency.

Based on medical record review and staff interview, the facility failed to develop Master Treatment Plans (MTPs) that identified individualized interventions by physicians, nurses, social workersmental health therapy aides, and Activity Therapists to address the specific treatment needs of 8 of 8 active sample patients (A, B, C, D, E, F, G and H). The listed interventions on the treatment plans were preprinted, routine, generic discipline functions that lacked a specific focus. This deficiency hampers staffs ability to provide comprehensive, integrated and individualized treatment.

Findings include:

A. Record Review (MTP dates in parentheses)

1. The MTPs for sample patients A (11/19/10), D (11/14/10), E (11/12/10), F (11/17/10), G (11/13/10) and H (11/19/10) listed the following generic physician interventions: "physician assessment to assess mood, mental status, and effectiveness of medication" and "Patient education related to effects and side effects of medication."

2. The MTPs for sample patients D (11/14/10), E (11/12/10), F (11/17/10),G (11/13/10) and H (11/19/10) listed the following generic RN intervention: "RN assessment to determine suicidality, mood, behavioral status, and patient's perception of effectiveness of medication." The MTPs for sample patients B (11/14/10) and C (11/19/10) listed the following generic RN intervention: "RN assessment to determine physical status and patient perception of effectiveness of medication."

3. A generic social work intervention listed for sample patients A, D, E, F, G and H (see above MTP dates) was "Process groups to provide healthy outlet to express thoughts and feelings." A generic social work intervention listed for all 8 sample patients was "Patient education regarding illness to promote self-care and prevent relapse."

4. A generic Mental Health Aide (MHA) intervention for all 8 sample patients (see above MTP dates) was "Goals and wrap-up groups assist patient in setting productive goals."

5. A generic Activity Therapy intervention for sample patients A, D, E, F, G and H (see above MTP dates) was "Therapy groups to provide patient skills in reality orientation and self awareness."

6. The MTP interventions for sample patients B (11/4/10) and C (11/19/10), both with a diagnosis of substance abuse, were identical except for a detox medication for patient B but not for patient C. The listed interventions were: "Physician's assessment to assess detox status and effectiveness of medications"; "Monitor vitals and physical symptoms to assess detox status and need for prn medications"; "RN assessment to determine physical status and patient perception of effectiveness of medication"; "Patient education related to effects and side effects of medications"; "Goals and wrap up groups to assist patient in setting productive goals"; "Psychoeducation group on coping skills, communication, relapse prevention, triggers, anger magmt [management] to develop self care and relapse prevention skills"; "Activities Therapy Groups to provide patient skills in self awareness and reality orientation"; "Patient education regarding illness to promote self-care and prevent relapse"; "Multifamily group prior to discharge to educate family in disease concept, relapse prevention and family support system"; "Assist patient in development of relapse prevention plan."

B. Staff Interview

On November 23, 2010 at approximately 3:00PM, the surveyors met with the Director of QI and Risk Management, the covering Director of Social Work, and the Director of Nursing (DON) about the failure of the facility to develop individualized interventions based on patient needs. The three interviewed Directors said that they did not know that interventions on the treatment plans needed to be patient specific.

Based on record review, policy review and staff interview, the facility failed to complete discharge summaries within 30 days of discharge as required by facility policy for 5 of 5 patients (I, J, K, L and M) whose records were reviewed. Failure to complete discharge summaries leads to lack of needed information being conveyed to future providers, potentially negatively impacting patients' continuation of care.

Findings include:

A. Record Review

Review of the discharge records for patients I, J, K, L and M revealed that none of the summaries were completed within 30 days as required by hospital policy.

B. Staff Interview

1. In an interview at approximately 4:00PM on 11/22/10, the Director of Quality Improvement (DQI) said that there is an ongoing problem with the physicians completing discharge summaries with in 30 days of discharging their patients. The DQI said that there is improvement for awhile and the problem occurs again.

2. In an interview on 11/23/10 at 10:30AM, the Medical Director acknowledged that completion of discharge summaries has been an ongoing problem

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor the care provided to patients at the facility. Specifically, the Medical Director failed to assure that:

I. Psychosocial Assessments were completed for 2 of 8 active sample patients (E and H). This deficient practice results in the multidisciplinary treatment team not having psychosocial data to be used for treatment planning, potentially compromising effective treatment of patients. (Refer to B108)

II. Psychiatric Evaluations for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) described the patient's memory functioning with supportive information. Failure to document memory testing compromises the identification of pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. The Master Treatment Plans for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) clearly identified interventions by physicians, nurses, social work, mental health therapy aides and Activity Therapists. The listed interventions on the treatment plans were preprinted, routine, generic discipline functions that lacked a specific focus. This deficiency hampers staffs ability to provide comprehensive, integrated and individualized treatment. (Refer to B122)

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor the care provided to patients at the facility. Specifically, the Medical Director failed to assure that:

I. Psychosocial Assessments were completed for 2 of 8 active sample patients (E and H). This deficient practice results in the multidisciplinary treatment team not having psychosocial data to be used for treatment planning, potentially compromising effective treatment of patients. (Refer to B108)

II. Psychiatric Evaluations for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) described the patient's memory functioning with supportive information. Failure to document memory testing compromises the identification of pathology which may be pertinent to the current mental illness. It also compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. The Master Treatment Plans for 8 of 8 active sample patients (A, B, C, D, E, F, G and H) clearly identified interventions by physicians, nurses, social work, mental health therapy aides and Activity Therapists. The listed interventions on the treatment plans were preprinted, routine, generic discipline functions that lacked a specific focus. This deficiency hampers staffs ability to provide comprehensive, integrated and individualized treatment. (Refer to B122)

Based on record (document) review and interview, it was determined that the facility failed to have a Director of Social work with a Master's Degree in Social Work, and also failed to have at least one staff member with the Master's Degree in Social Work who was responsible for the social work staff's performance.

Findings include:

A. Record Review

1. A review of credential files provided by the facility revealed that the Director of Social work did not have MSW qualification.

2. Review of the job description of the staff social worker who had MSW qualification revealed that the job description did not include any supervisory responsibilities; the job description was identical to that of other social worker/counselors who did not have MSW qualifications.

B. Staff Interviews

1. In an interview on 11/22/2010 at 2:00PM, the full time Counselor 2 (who does not have MSW qualification) stated that she performs the duties of staff social worker and that she is not supervised by a MSW social worker.

2. In an interview on 11/22/2010 at 2:15PM, the full time Counselor 3 with MSW qualification stated that she performs the duties of a staff social worker/counselor only for her assigned inpatients, and that she does not have any supervisory responsibilities for other social workers at the facility.

3. In an interview on 11/23/2010 at 3:45PM, the acting Director of the Social Work department acknowledged that the Director of the social work department did not have a Master's Degree in social work. She also stated that other Masters-prepared social work staff (one full time and one part time) did not perform any supervisory duties. The Acting Social Work Director stated "Our part time social worker (counselor 4) who is an MSW reviews some psychosocial assessments." The Acting Social Word Director did not know the work schedule of the part time social worker. The part time social worker with the MSW was not available for interview.