HospitalInspections.org

Based on record review and interview, the facility failed to ensure that Social Work Assessments for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2) addressed the anticipated role of the Social Worker in treatment and discharge planning. This failure results in a lack of information to formulate Social Service interventions for patients.

Findings include:

A. Record Review

The "Integrated Assessment Section IV - Social History" was a multi-page preprinted form filled in by hand by the assigned social worker/therapist. It collected basic social information that can be used in treatment and discharge planning, with the last section labeled "Preliminary Discharge Plans." This section contained check boxes for "Anticipated Level of Care Needs" with four options to check and "Community Resources Needed" with four options to check followed by several lines to add more planning. The assessment forms lacked the option to discuss any treatment groups led by social workers or counseling sessions that the social might undertake. Thus, specific roles for social work in treatment were not identified, and the information put in the discharge plan was very limited as to the role of the social worker.

1. Patient A1 (admitted 11/18/10) had a social assessment completed 11/18/10. The Preliminary Discharge Plans section did not have any boxes checked. A handwritten note said "Pt. return home family confirms outpt followup [sic]." No further role for the Social Worker (SW) was identified.

2. Patient B1 (admitted 12/2/10 after just being discharged 11/30/10) had a social assessment update completed 12/4/10 with the original assessment done 11/4/10. The original assessment had nothing checked or written in the Preliminary Discharge Plans section while the update listed "1) Pt. will return home" and "2) Will f/u with psychiatrist for med mgmt." No role for the SW in discharge planning was identified.

3. Patient B2 (admitted 12/3/10) had a social assessment completed 12/8/10. The Preliminary Discharge Plans section did not have any boxes checked. A handwritten note said "Pt. to followup with previous providers," "Pt. to remain med compliant," "Pt. to return home with family" and "Pt. to return to work as recommended by providers." The role for the Social Worker was not identified.

4. Patient C1 (admitted 12/4/10) had a social assessment completed 12/6/10. The Preliminary Discharge Plans section did not have any boxes checked. A handwritten note said "Pt. will d/c home to Mom and Child, go to all scheduled appts. And use NA (narcotics anonymous) as a way to build a (illegible) support network." No further role for the SW in discharge planning or treatment was identified.

5. Patient D1 (admitted 12/3/10) had a social assessment update completed 12/3/10 after being discharged two weeks earlier with an original social assessment done 11/11/10. Both the original assessment and update had "return to (town)" written in the Preliminary Discharge Plans section with the update having the AA (Alcoholics Anonymous) box checked. No role for the SW in discharge planning was identified.

6. Patient E1 (admitted 12/6/10) had a social assessment completed 12/7/10. The Preliminary Discharge Plans section had the "acute care" box checked. A handwritten note said "Pt. will return home with M upon discharge [sic]." No role for the (SW) was identified.

7. Patient F1 (admitted 12/2/10) had a social assessment completed 12/3/10. The Preliminary Discharge Plans section had the "acute care" box checked. A handwritten note said "Pt. will return home with family upon discharge." No role for the (SW) was identified.

8. Patient G1 (admitted 11/30/10) had a social assessment completed 12/2/10. The Preliminary Discharge Plans section had the "AA" box checked and written was "Pt. will return to military providers." No role for the (SW) was identified

9. Patient H1 (admitted 12/1/10) had a social assessment completed 12/3/10. The Preliminary Discharge Plans section had a handwritten note that said "Pt. to be referred back to Bx Health with BAMC [sic]." No further role for the (SW) was identified

10. Patient H2 (admitted 11/18/10) had a social assessment completed 11/19/10. The Preliminary Discharge Plans section had a handwritten note that said "Refer back to Ft. Polk." No further role for the (SW) was identified

B. Staff Interview

In an interview on 12/9/10 at 2:15PM, the Director of Social Services agreed that the social assessment should include the specific roles of the social worker in discharge planning and treatment, and that the present pre-printed form discourages entering more than the most basic, non-specific discharge planning information.

Based on record review and interview, the facility failed to provide psychiatric evaluations that reported recent and remote memory functioning in measurable, behavioral terms, clearly reflecting the patient's abilities to function in those areas, for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2). This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

A. Record Review

The Mental Status Exam (MSE) was a section of the Psychiatric Evaluation which was on a preprinted form filled in by hand. It contained of many aspects of the MSE, each evaluated by selecting check boxes. The section entitled "Memory" gave choices of "Intact" or "Impaired." The item "Impaired" was further divided into three check boxes of "Immediate"; "Present" and "Remote". There was no description of the tests performed to evaluate these aspects of memory nor were blank lines provided to describe further the tests that were performed.

1. Patient A1 had a Psychiatric Evaluation done 11/18/10. The MSE had "Impaired memory" checked along with present and remote also checked. The specific memory tests performed were not documented.

2. Patient B1 had an MSE update (readmission) done 12/2/10 which listed "A & O x 3" for orientation and memory. The initial MSE done 11/4/10 had "Intact memory" checked with no specific testing documented.

3. Patient B2 had a psychiatric evaluation done 12/4/10. The MSE had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

4. Patient C1 a psychiatric evaluation done 12/5/10. The MSE had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

5. Patient D1 had a psychiatric evaluation done 12/3/10. The MSE had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

6. Patient E1 had a psychiatric evaluation done 12/7/10. The MSE had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

7. Patient F1 had a psychiatric evaluation done 12/3/10 with an MSE which had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

8. Patient G1 had a psychiatric evaluation done 12/2/10 with an MSE which had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

9. Patient H1 had a psychiatric evaluation done 12/2/10 with an MSE which had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

10. Patient H2 had a psychiatric evaluation done 11/19/10 with an MSE which had "Intact memory" checked. This evaluation lacked documentation of specific testing to evaluate memory function.

B. Staff Interview

In an interview on 12/07/10 at 1:30PM with the Medical Director, the lack of documentation of memory function, including which tests were performed for the mental status exam, was discussed. The Medical Director acknowledged the above findings and stated that he needed to talk with the other attending psychiatrists (about the deficient documentations).

Based on review of the records and interviews the facility failed to develop individualized treatment plans that clearly delineated interventions to address specific patient problems and assist patients to accomplishment treatment objectives. Specifically, the "Master Treatment Plans" failed to:

I. Identify group and individual active treatment measures that addressed patients' individualized presenting problems and treatment goals. Instead, routine and generic discipline functions were listed as treatment interventions for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2).

II. Specify how interventions would be delivered (in group or individual sessions) and/or include the frequency of contact for treatment interventions for 10 of 10 sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2).

Findings include:

I. Generic and Routine Discipline Functions

A. Record Review

The treatment plans for the following sample patients were reviewed (dates of plans in parentheses): A1 (11/18/10); B1 (12/2/10); B2 (12/3/10); C1 (12/4/10); D1 (12/3/10); (E1 (12/6/10); F1 (12/2/10); G1 (11/30/10); H1 (12/1/10); and H2 (11/18/10). The plans contained the following generic and routine discipline functions written as treatment interventions instead of specific and individualized interventions to assist patients to accomplish treatment goals.

1. Patient A1

a. Problem Description: "Harm to Self or Others - erratic driving, threatened individuals." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as ________; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

b. Problem Description: "Psychotic Symptoms - hallucinations, delusions, paranoia." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess/adjust medication efficacy during each visit and/or as needed"

Nursing Interventions: "Assess for severity of impairment in daily functioning every shift; Monitor for aggression escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward effects of prescribe medication every shift."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

2. Patient B1

a. Problem Description: "Harm to Self or Others - "Threats to hang self; Hx [history] of provoking fights." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolating; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc. [sic]."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

b. Problem Description: "Psychotic Symptoms - hearing voices, seeing [sic]." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Intervention: "Assess/adjust medication efficacy during each visit and/or needed."

(No RN or STS interventions checked on the treatment plan for this problem).

3. Patient B2

a. Problem Description: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolation; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

b. Problem Description: "Depressed Mood - depressed mood, hopelessness, helpless." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

(No STS interventions checked on the treatment plan for this problem).

4. Patient C1

a. Problem Description: "Depressed Mood: SI [suicidal ideation] [with] plans to OD [overdose], Hopeless, irritable." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

(No STS Interventions checked on the treatment plan for this problem).

b. Problem Description: "Harm to Self or Others - Suicidal ideation [with] plan to OD [overdose] on Heroin, $100 Heroin binge x 10 days." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as burning, cutting; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking", etc."

(No Therapist or STS Interventions documented for this problem).

5. Patient D1

a. Problem Description: "Depressed Mood: Anergia, anhedonia, worthlessness/guilt." The treatment plan contained the following preprinted generic and routine discipline functions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Intervention: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services): "Closely supervise the patient's use of potentially dangerous objects."

6. Patient E1

a. Problem Description: "Suicidal Thoughts - wants someone to kill him." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as self isolating; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

b. Problem Description: "Pt [patient] depressed with SI [suicidal ideation]."

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Interventions: "Coordinate discharge placement, aftercare, and community resources."

c. Problem Description: "Psychotic Symptoms - A/H [Auditory Hallucinations] - hears voices telling pt [patient] to kill himself."

Physician Interventions: "Assess/adjust medication efficacy during each visit and/or as needed."

Nursing Interventions: "Assess for severity of impairment in daily functioning every shift; Monitor for aggression escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward effects of prescribe medication every shift."

Therapist Intervention: "Encourage patient to verbalize thoughts and feelings during each encounter."

STS Intervention [Specialized Therapeutic Services]. "Provide safe leisure environment on unit until safety precautions removed; after which off-unit activities may be used;" Will report changes in symptoms and severity to Nursing/MD."

7. Patient F1

a. Problem Description: "Increased agg [aggression] toward others" The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as threatening others; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking", etc.

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

b. Problem Description: "pt [patient] depressed with SI [suicidal Ideation]." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Intervention: "Coordinate discharge placement, aftercare, and community resources."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of potentially dangerous objects."

c. Problem Description: "pt [patient] hits, kicks, scratches sister." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess medication efficacy during each visit and/or needed and obtain informed consent for psychoactive medications prior to initiating each."

Nursing Interventions: "Monitor desired and untoward effects of prescribed medication; Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear."

STS (Specialized Therapeutic Services) Intervention: "Provide safe leisure environment on unit until safety precautions removed; after which off-unit activities may be used."

8. Patient G1

a. Problem Description: "Harm to self or others. - SI [suicidal ideation] - attempts x3 by OD [overdose]." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolation, pacing; Positive reinforcement for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion, "cheeking," etc; and Provide/maintain safe environment."

STS (Specialized Therapeutic Services) Intervention: "Closely supervise the patient's use of or [sic] potentially dangerous objects."

b. Problem Description: "Depressed Mood - Mood instability, crying spells, self-medicating with ETOH [alcohol], violent/aggression, decreased trust." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

Therapist Intervention: "Provide therapeutic space via groups and/or individual therapy whereby patient can express feelings and how to cope with them; Coordinate discharge placement, aftercare, and community resources; Be consistent with client. Set and maintain clear expectations."

c. Problem Description: "Rehabilitation from chemical dependency. - ETOH [alcohol]." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Intervention: "Will assess medication for effectiveness in stabilization of mood."

Nursing Intervention: "Monitor for signs and symptoms of relapse potential and communicate to treatment team."

9. Patient H1

a. Problem Description: "PTSD - increased nightmares, increased hyper arousal; increased avoidance; increased agitation." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Intervention: "Daily [sic] MD med [medication] consult 1:1."

Nursing Intervention: "24 hour nsg [nursing] observation; encourage listening to PE tape."

b. Problem Description: "Harm to self or others - SI [suicidal ideation]; history of HI [homicidal ideation] towards [sic]." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Interventions: "Assess and adjust medication as needed with length of stay; Monitor medication levels one time per week or as needed; and Obtain informed consent for psychoactive medications."

Nursing Interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as anxious [sic]; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for xxx."

10. Patient H2

a. Problem Description: "PTSD - increased anxiety; increase hyper arousal; increased aggression; increased re-remembering." The treatment plan contained the following preprinted generic and routine discipline functions written as treatment interventions:

Physician Intervention: "Daily 1:1 [sic] MD med [medication] consult."

Nursing Intervention: "24 hour nsg [nursing] observation."

STS (Specialized Therapeutic Services) Intervention: "Provide for positive coping skills for PTSD symptoms; Alert nursing staff of concerns."

B. Staff Interviews:

1. In an interview on 12/9/10 at 11:10a.m. with RN5, the treatment plan for Patient F1 was reviewed. RN5 acknowledged that the treatment plan contained generic and routine nursing tasks that were written as nursing interventions.

2. In an interview on 12/9/10 at 11:30a.m. with RN3, the treatment plan for Patient E1 was reviewed. RN3 acknowledged that the treatment plan contained generic and routine nursing tasks that were written as nursing interventions.

3. In an interview on 12/9/10 at 1:10p.m. with the Director of Therapeutic Activities, the treatment plan for Patient FI was reviewed. The Director of Therapeutic Activities acknowledged that STS interventions were not specific. She stated, "The treatment plan was changed to meet other regulatory agencies' requirements."

4. In an interview on 12/9/10 at 2:30p.m. with RN4, the treatment plan for Patient G1 was reviewed. RN4 acknowledged that the treatment plan contained generic and routine nursing tasks that were written as nursing interventions.

II. Lack of Individualized Interventions and frequency of contact

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (11/18/10); B1 (12/2/10); B2 (12/3/10); C1 (12/4/10); D1 (12/3/10); (E1 (12/6/10); F1 (12/2/10); G1 (11/30/10); H1 (12/1/10); and H2 (11/18/10). These plans contained the following interventions that were not individualized, intervention statements for patients. The interventions also had identical or similar wording and did not specify the frequency of contact and/or how the intervention would be delivered (individual or group sessions) by the Registered Nurse, Therapist, and Specialized Therapeutic Services (STS) staff.

1. Patient A1

a. Problems: "Harm to Self or Others - erratic driving, threatened individuals." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving, and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: "Psychotic Symptoms - hallucinations, delusions, paranoia." RN Intervention: "Provide medication education prior to initiation of therapy and as needed during continuation of same at time of each administration." "Educate patient/family regarding disease process."

STS Intervention: "Throughout length of stay, provide variety of activities to include: Creative self expression, cognitive skill development, physical activity, music therapy, leisure education and initiatives."

2. Patient B1

a. Problem: "Harm to Self or Others - Threats to hang self; Hx [history] of provoking fights." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: "Psychotic Symptoms - hearing voices, seeing [sic]." Therapist Intervention: "See patient weekly for support and education related to hallucinations;" "Encourage patient to verbalize thoughts and feelings during each encounter."

3. Patient B2

a. Problem: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

Therapist Intervention: "Discuss with patient how to identify and break out of self-destructive patterned behavior." "Discuss the concept of having self-harm ideas as distinct from putting those ideas into action."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: "Depressed Mood - depressed mood, hopelessness, helpless." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

4. Patient C1

a. Problem: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

b. Problem: "Depressed Mood - SI [suicidal ideation] [with] plans to OD [overdose], Hopeless, irritable." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

5. Patient D1

a. Problem: "Depressed Mood: Anergia, anhedonia, worthlessness/guilt." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

6. Patient E1

a. Problem: "Harm to Self or Others: RN Intervention: "Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process reinforcing as needed."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: Depressed Mood: RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

7. Patient F1

a. Problem: "Harm to Self or Others: RN Intervention: Educate patient/family regarding disease process reinforcing as needed."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: Depressed Mood: RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

8. Patient G1

a. Problem - "Harm to Self or Others." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed." "Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem - "Depressed Mood." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

Therapist Intervention: "Encourage patient to identify thoughts related to overcoming feelings of depression." "Work with patient on the establishment of short and long term goals."

9. Patient H1

a. Problem: "Harm to Self or Others." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed." "Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge."

Therapist Intervention: "Discuss with patient how to identify and break out of self-destructive patterned behavior." "Discuss the concept of having self-harm ideas as distinct from putting those ideas into action."

STS Intervention [Specialized Therapeutic Services]: "Provide daily therapeutic activity to assist with positive coping, problem solving and decision making skills." "Provide daily therapeutic activity to increase awareness or self through ongoing interest inventory."

b. Problem: "PTSD [Post Traumatic Stress Disorder]." RN Intervention: "Teach sleep hygene [sic] education."

STS Intervention [Specialized Therapeutic Services]: "Art/Music Therapy daily to develop coping skills."

10. Patient H2

a. Problem: "PTSD [Post Traumatic Stress Disorder]." RN Intervention: "Process with [Patient's name] on identifying triggers. "

STS Intervention [Specialized Therapeutic Services]: "Provide for [positive] coping skills for PTSD [Post Traumatic Stress Disorder] symptoms."

B. Staff Interviews

1. In an interview on 12/9/10 at 11:10a.m. with RN5, the intervention statements on the treatment plan for Patient F1 were reviewed. RN5 confirmed RN interventions did not specify the frequency of contact or whether interventions would be implemented in individual or groups sessions.

2. In an interview on 12/9/10 at 11:3 a.m. with RN3, the intervention statements on the treatment plan for Patient E1 were reviewed. RN3 confirmed RN interventions did not specify the frequency of contact or whether interventions would be implemented in individual or groups sessions.

3. In an interview on 12/9/10 at 2:30p.m. with RN4, the intervention statements on the treatment plan for Patient G1 were reviewed. RN4 confirmed RN interventions did not specify the frequency of contact or whether interventions would be implemented in individual or groups sessions.

Based on record review and interview, the facility failed to ensure that Registered Nurse Interventions assigned on the treatment plan were documented in the medical record. Specifically, the facility failed to include the patients' attendance or non-attendance, topics discussed, and patients' level of participation in nursing interventions for 5 of 10 sample patients (E1, F1, G1, H1 and H2). This failure potentially hinders the treatment team from determining the patient's response to treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when/if the patient does not respond to treatment interventions.

Findings include:

A. Record Review

1. Patient E1's "Acute Master Treatment Plan" dated 12/6/10 contained the following RN interventions for Problem #1A - Harm to self or others: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge; Educate patient/family regarding disease process reinforcing as needed." There was no documentation regarding the topics discussed, the patient's response, or the patient's level of participation and understanding.

2. Patient F1's "Acute Master Treatment Plan" dated 12/2/10 contained the following RN interventions for Problem #1A - Harm to self or others: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge; Educate patient/family regarding disease process reinforcing as needed." There was no documentation regarding the topics discussed, the patient's response, or the patient's level of participation and understanding.

3. Patient G1's "Acute Master Treatment Plan" dated 11/30/10 contained the following RN interventions for Problem #1A: Harm to self or others. "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge; Educate patient/family regarding disease process reinforcing as needed" and Problem 3A: "PTSD [Post Traumatic Stress Disorder]:" "Teach sleep hygene [sic] education." There was no documentation regarding the topics discussed, the patient's response, or the patient's level of participation and understanding.

4. Patient H1's "Acute Master Treatment Plan" dated 12/1/10 contained the following RN interventions for Problem #1A: Harm to self or others. "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge; Educate patient/family regarding disease process reinforcing as needed" and Problem 3F: "Depressed Mood." "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood." There was no documentation regarding the topics discussed, the patient's response, or the patient's level of participation and understanding.

5. Patient H2's "Acute Master Treatment Plan" dated 11/10/10 contained the following RN intervention - Problem 3A: "PTSD [Post Traumatic Stress Disorder]": "Teach sleep hygene [sic] education." There was no documentation regarding the topics discussed, the patient's response, or patient's level of participation and understanding.

B. Staff Interviews:

1. In an interview on 12/9/10 at 11:10a.m. with RN5, the medical record for Patient F1 was reviewed to locate treatment notes for interventions identified on the treatment plan assigned to the registered nurse. RN5 confirmed that there was no documentation of interventions on the treatment plan found in the medical record reflecting contact with the RN in individual or group sessions, topic(s) discussed, and/or patient's response.

2. In an interview on 12/9/10 at 11:30a.m. with RN3, the medical record for Patient E1 was reviewed to locate treatment notes for interventions identified on the treatment plan assigned to the registered nurse. RN3 confirmed that there was no documentation of interventions on the treatment plan found in the medical record reflecting contact with the RN in individual or group sessions, topic(s) discussed, and/or patient's response.

3. In an interview on 12/9/10 at 2:30p.m. with RN4, the medical record for Patient G1 was reviewed to locate treatment notes for interventions identified on the treatment plan assigned to the registered nurse. RN4 confirmed that there was no documentation of interventions on the treatment plan found in the medical record reflecting contact with the RN in individual or group sessions, topic(s) discussed, and/or patient's response.

4. In an interview on 12/9/10 at 3:10p.m. with the Director of Nursing (DON), the intervention statements on the treatment plan for Patients E1, F1 and G1 were reviewed. The DON acknowledged that the RN interventions did not specify the frequency of contact or whether interventions would be implemented in individual or groups sessions.

Based on record review and interview, the Medical Director failed to assure quality and appropriateness of care for 10 of 10 active patients. Specifically, the Medical Director failed to:

I. Ensure that the psychiatric evaluations for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2) reported recent and remote memory functioning in measurable, behavioral terms that would clearly reflect the patients' abilities to function in those areas. This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Ensure that interventions written on the Master Treatment Plans for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2) were individualized and clearly addressed specific patient problems, assisting patients to accomplishment treatment objectives. Instead, routine and generic discipline functions were listed as treatment interventions for 10 of 10 active sample patients. (Refer to B122)

Based on observation, record review, and interview, the Director of Nursing (DON) failed to:

I. Ensure that "Master Treatment Plans" contained nurses' active treatment measures that addressed patients' individualized presenting problems and treatment goals. The treatment plans included routine and generic nursing functions that were listed as treatment interventions for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2).

II. Ensure that "Acute Master Treatment Plans" specified how nursing interventions would be delivered (group or individual sessions) and/or included the frequency of contact for nursing interventions 10 of 10 sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1, and H2).

These deficiencies result in failure to guide treatment staff regarding the specific treatment interventions prescribed by the treatment team, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

I. Generic and Routine Nursing Functions

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 11/18/10); B1 (12/2/10); B2 (12/3/10); C1 (12/4/10); D1 (12/3/10); (E1 (12/6/10); F1 (12/2/10); G1 (11/30/10); H1 (12/1/10); and H2 (11/18/10). These plans contained the following identical routine nursing functions for all patients in the sample written as treatment interventions, instead of specific and individualized interventions to assist patients to accomplish treatment goals.

1. Patient A1

a. Problem Description: "Harm to Self or Others - erratic driving, threatened individuals." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as ________; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

b. Problem Description: "Psychotic Symptoms - hallucinations, delusions, paranoia." The treatment plan contained the following preprinted generic and routine nursing interventions: "Assess for severity of impairment in daily functioning every shift; Monitor for aggression escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward effects of prescribe medication every shift."

2. Patient B1

a. Problem Description: "Harm to Self or Others - Threats to hang self; Hx [history] of provoking fights." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolating; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

3. Patient B2

a. Problem Description: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." The treatment plan contained the following preprinted generic and routine nursing functions written as nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolation; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

b. Problem Description: "Depressed Mood - depressed mood, hopelessness, helpless." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

4. Patient C1

a. Problem Description: "Depressed Mood: SI [suicidal ideation] [with] plans to OD [overdose], Hopeless, irritable." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

b. Problem Description: "Harm to Self or Others - Suicidal ideation [with] plan to OD [overdose] on Heroin, $100 Heroin binge x 10 days." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as burning, cutting; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

5. Patient D1

a. Problem Description: "Depressed Mood: Anergia, anhedonia, worthlessness/guilt." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

6. Patient E1

a. Problem Description: "Suicidal Thoughts - wants someone to kill him." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as self isolating; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking," etc."

b. Problem Description: "Pt [patient] depressed with SI [suicidal ideation]." Nursing Interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

c. Problem Description: "Psychotic Symptoms - A/H [Auditory Hallucinations] - hears voices telling pt [patient] to kill himself." Nursing Interventions: "Assess for severity of impairment in daily functioning every shift; Monitor for aggression escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward effects of prescribe medication every shift."

7. Patient F1

a. Problem Description: "Increased agg [aggression] toward others." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as threatening others; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "cheeking", etc.

b. Problem Description: "pt [patient] depressed with SI [suicidal Ideation]." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

c. Problem Description: "pt [patient] hits, kicks, scratches sister." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor desired and untoward effects of prescribed medication; Use de-escalation techniques to prevent aggressive acting out or violent episodes whenever signs of escalation appear."

8. Patient G1

a. Problem Description: "Harm to self or others. - SI [suicidal ideation] - attempts x3 by OD [overdose]." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as isolation, pacing; Positive reinforcement for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion, "cheeking," etc; and Provide/maintain safe environment."

b. Problem Description: "Depressed Mood - Mood instability, crying spells, self-medicating with ETOH [alcohol], violent/aggression, decreased trust." The treatment plan contained the following preprinted generic and routine nursing interventions: "Monitor and check for medication efficacy and side effects; Use active listening and empathetic responses; Monitor ADL performance for signs and symptoms of depression; Monitor sleeping patterns for sign and symptoms of depression."

c. Problem Description: "Rehabilitation from chemical dependency. - ETOH [alcohol]." The treatment plan contained the following preprinted generic and routine nursing intervention: "Monitor for signs and symptoms of relapse potential and communicate to treatment team."

9. Patient H1

a. Problem Description: "PTSD - increased nightmares, increased hyper arousal; increased avoidance; increased agitation." The treatment plan contained the following preprinted generic and routine nursing interventions: "24 hour nsg [nursing] observation; encourage listening to PE tape."

b. Problem Description: "Harm to self or others - SI [suicidal ideation]; history of HI [homicidal ideation] towards [sic]." The treatment plan contained the following preprinted generic and routine nursing interventions: "Perform risk assessment every shift; Perform safety checks according to precaution level every 15 minutes throughout the length of stay; observe for behaviors that are precursors to self-destructive acts such as anxious [sic]; Positive reinforcement for specific demonstration of self-control; and monitor and check for medication as prescribed for ingestion, "Cheeking", etc."

10. Patient H2

a. Problem Description: "PTSD - increased anxiety; increase hyper arousal; increased aggression; increased re-remembering." The treatment plan contained the following preprinted generic and routine nursing intervention: "24 hour nsg [nursing] observation."

B. Staff Interviews:

1. In an interview on 12/9/10 at 3:10p.m., the treatment plans for Patient E1, F1, and G1 were reviewed with the DON. She agreed that the treatment plan contained statements of nursing functions rather than specific nursing interventions to address presenting symptoms.

II. Failure to specify delivery method (modality) and/or frequency of contact

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): E1 (12/6/10); F1 (12/2/10); G1 (11/30/10); H1 (12/1/10); and H2 (11/18/10). These plans did not specify the frequency of contact and/or how the intervention would be delivered (individual or group sessions) by the Registered Nurse.

1. Patient A1

a. Problems: "Harm to Self or Others - erratic driving, threatened individuals." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed."

b. Problem: "Psychotic Symptoms - hallucinations, delusions, paranoia." RN Intervention: "Provide medication education prior to initiation of therapy and as needed during continuation of same at time of each administration." "Educate patient/family regarding disease process."

2. Patient B1

a. Problem: "Harm to Self or Others - Threats to hang self; Hx [history] of provoking fights." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

3. Patient B2

a. Problem: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

b. Problem: "Depressed Mood - depressed mood, hopelessness, helpless." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

4. Patient C1

a. Problem: "Harm to Self or Others - S.I. [suicidal ideation] [with] continuous thoughts & Hx [history] of cutting." RN Intervention: "Assist patient in developing relapse and crisis plan, addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process."

b. Problem: "Depressed Mood - SI [suicidal ideation] [with] plans to OD [overdose], Hopeless, irritable." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

5. Patient D1

a. Problem: "Depressed Mood: Anergia, anhedonia, worthlessness/guilt." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

6. Patient E1

a. Problem: "Harm to Self or Others: RN Intervention: Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge;" "Educate patient/family regarding disease process reinforcing as needed."

b. Problem: Depressed Mood: RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

7. Patient F1

a. Problem: "Harm to Self or Others:" RN Intervention: "Educate patient/family regarding disease process reinforcing as needed."

b. Problem: Depressed Mood: RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

8. Patient G1

a. Problem - "Harm to Self or Others." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed." "Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge."

b. Problem - "Depressed Mood." RN Intervention: "Work with patient to identify coping methods to deal with stressors/triggers that contribute to depressed mood."

9. Patient H1

a. Problem: "Harm to Self or Others." RN Intervention: "Educate patient/family regarding disease process reinforcing as needed." "Assist patient in developing relapse and crisis plan addressing how he/she would handle self-harm urges after discharge."

b. Problem: "PTSD [Post Traumatic Stress Disorder]." RN Intervention: "Teach sleep hygene [sic] education."

10. Patient H2

a. Problem: "PTSD [Post Traumatic Stress Disorder]." RN Intervention: "Process with [Patient's name] on identifying triggers."

B. Staff Interviews

1. In an interview on 12/9/10 at 3:10p.m. with the Director of Nursing (DON), the intervention statements on the treatment plan for Patients E1, F1 and G1 were reviewed. The D.O.N. acknowledged RN interventions did not specify the frequency of contact or whether interventions would be implemented in individual or groups sessions.

III. Ensure that nursing interventions listed on the "Interdisciplinary Treatment Plan" were documented by Registered nurses for 5 of 10 active sample patients (E1, F1, G1, H1 and H2). Specifically, there was no documentation regarding interventions reflecting the topic discussed and patient's response, including level of participation and understanding. This failure potentially hinders the treatment team from determining the patient's response to treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

Based on record review and interview, the Director of Social Services failed to ensure that Social Work Assessments for 10 of 10 active sample patients (A1, B1, B2, C1, D1, E1, F1, G1, H1 and H2) addressed the anticipated role of the Social Worker in treatment and discharge planning. (Refer to B 108)