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Based on interview and document review, the facility failed to ensure that 4 of 8 active sample patients (7, 9, 11, and 13) and 9 discharged patients, including sample Patient D6, were hospitalized based on the need for acute inpatient treatment. Four of 8 active sample patients (7, 9, 11, and 13) who did not require acute inpatient treatment were admitted to the "Behavioral Health Behavior Analysis Unit" (BAU), a subacute unit included by the facility as an inpatient unit. Patients were admitted for extended periods of time to the BAU program for containment and the provision of behavioral interventions. In addition, 9 discharged patients over the previous year, including Patient D6, were admitted to the acute inpatient unit on "Respite" status. Patients admitted on "Respite" status received outpatient treatment after admission to the acute inpatient unit. This results in patients who do not require acute inpatient treatment being hospitalized for containment and behavioral interventions or for the provision of outpatient services. (Refer to B125)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues and conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for 8 of 8 sample patients (1, 2, 7, 9, 10, 11, 13, and 14). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

1. Patient 1

The social work assessment for Patient 1 dated 5/7/13 stated the "Conclusions/Recommendations" were "Child is...presenting with SI (suicidal ideation) with attempt. Child denies HI (homicidal ideation) and psychosis. After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

2. Patient 2

The social work assessment for Patient 2 dated 6/28/13 stated the "Conclusions/Recommendations" were "Child is...presenting with mood dysregulation et (and) impulsivity leading to AWOL (absent without leave), aggression et (and) HI (homicidal ideation). After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

3. Patient 7

The social work assessment for Patient 7 dated 12/12/12 stated the "Conclusions/Recommendations" were "Child is...presenting with mood dysregulation et (and) impulsivity leading to increasing aggression et (and) SIB (self injurious behavior). After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

4. Patient 9

The social work assessment for Patient 9 dated 4/9/13 stated the "Conclusions/Recommendations" were "Child is...presenting with mood dysregulation et (and) impulsivity leading to aggression, SI (suicidal ideation), SIB (self injurious behavior), et (and) HI (homicidal ideation) . After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

5. Patient 10

The social work assessment for Patient 10 dated 7/2/13 stated the "Conclusions/Recommendations" were "Child is...presenting with aggression. Child denies SI (suicidal ideation), HI (homicidal ideation), SIB (self injurious behavior), and psychosis. After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

6. Patient 11

The social work assessment for Patient 11 dated 12/3/13 stated the "Conclusions/Recommendations" were "Child was admitted to Respite after consulting with on call physician due to SI (suicidal ideation) with plan." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

7. Patient 13

The social work assessment for Patient 13 dated 3/25/13 stated the "Conclusions/Recommendations" were "Child is...with mood dysregulation et (and) impulsivity leading to defiance et (and) aggression. After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

8. Patient 14

The social work assessment for Patient 14 dated 6/22/13 stated the "Conclusions/Recommendations" were "Child is...presenting with mood dysregulation et (and) impulsivity leading to SI (suicidal ideation) et (and) SIB (self injurious behavior). After consulting with on call physician, child met criteria for inpatient hospitalization." This psychosocial assessment did not contain sufficient social information and evaluation of social functioning level to utilize in developing an effective and meaningful treatment plan.

B. Interview

During an interview with the Director of Social Work 7/9/13 at 3:30 p.m., she agreed that the social work assessments did not contain a social evaluation of strength/deficits and high risk psychosocial issues and conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning.

Based on record review and staff interview, the facility failed to ensure a complete psychiatric evaluation for 1 of 1 discharged patient (D6). This resulted in no current comprehensive psychiatric assessment to justify the diagnosis, to plan and oversee treatment, and to assess patient response to treatment.

Findings include:

A. Record Review

Patient D6 was admitted on 4/26/13 on "Respite" status and discharged on 5/1/13. No psychiatric evaluation was completed for this patient.

B. Staff Interview

During an interview with the Medical Director on 7/8/13 at 2:30 p.m., he stated that "Respite" patients were not considered inpatients although they were admitted to the acute inpatient unit. He acknowledged that psychiatric evaluations were not completed for "Respite" status patients.

Based on record review and staff interview, the facility failed to ensure complete psychiatric evaluations within 60 hours of admission for 4 of 8 active sample patients (1, 2, 10 and 11). The absence of a comprehensive psychiatric assessment completed within 60 hours hampered staff's ability to direct treatment, and delineate risk factors and strengths for patients' treatment plans and a failure to substantiate the diagnoses.

Findings are:

I. Record review:

A. Patient 1 was admitted to the facility on 6/28/13. The psychiatric evaluation was not transcribed until 7/1/13.

B. Patient 2 was admitted to the facility on 5/7/13. The psychiatric evaluation was not transcribed until 5/10/13.

C. Patient 10 was admitted to the facility on 7/2/13. The psychiatric evaluation was not transcribed until 7/5/13.

D. Patient 11 was admitted to the facility on 12/11/12. The psychiatric evaluation was not transcribed until 12/18/12.

II. Staff interviews:

A. During an interview with Unit Secretary 1 on 7/8/3 at 11:45 a.m., she stated that Patient 2 and Patient 10 did not have a completed psychiatric evaluation in the medical records. She stated these psychiatric evaluations were "probably in medical records" [department] and had not been placed into the medical record.

B. During an interview with the Medical Director on 7/9/13 at 2:30 p.m., he acknowledged that the psychiatric evaluations for these patients had not been completed and placed in the medical record within 60 hours.

Based on record review and interview, it was determined that the facility failed to develop Master Treatment Plans (MTPs) for 7 of 8 active sample patients (1, 2, 7, 9, 10, 13 and 14) that included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the MTPs were generic pre-printed interventions not linked to specific goals. Failure to clearly describe specific modalities on patients' MTPs may hamper staff's ability to provide treatment based on individual patient needs.

A. Record Review

1. Patient 1: Admitted on 5/7/13 with MTP dated 5/8/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The Advanced Practice Registered Nurse (APRN) intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The interventions to be provided by social work were: "Individual therapy will be offered a minimum of 2 times per week to focus on SI (suicidal ideation). Family therapy will be offered one time per week to increase communication. Group therapy will be offered a minimum of 2 times per week to rotate cluster group topics in an individualized format."

2. Patient 2: Admitted on 6/28/13 with MTP dated 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." No interventions to be provided by social work were included on the treatment plan.

3. Patient 7: Admitted 12/12/12 with MTP update on 6/28/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The interventions to be provided by social work were: "Individual therapy will be offered a minimum of two times weekly. Family therapy will be offered a minimum of one time weekly to open communication among [the facility], [social services], and [Patient 7]. Group therapy will be offered 5 times weekly to address cluster specific topics."

4. Patient 9: Admitted 4/9/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The interventions to be provided by social work were: "Individual therapy will be offered to [Patient 9] a minimum of 2 times in order address [sic] SI (suicidal ideation) with plan and aggression l/t (leading to) HI (homicidal ideation). Family therapy will be offered a minimum of one time per week to enable open family communication. Group therapy will be offered a minimum of 5 times weekly, focusing on cluster-specific topics."

5. Patient 10: Admitted 7/2/13 with MTP updated 7/11/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The only interventions to be provided by social work were: "Ind. (individual) therapy will be offered 2x (times) per week to focus on agg (aggression). Family therapy will be offered 1x per week to (increase) communication. Group therapy will be offered 2x per week to rotate cluster group topics."

6. Patient 13: Admitted 3/25/13 with MTP updated 6/18/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "will clarify M.S. (mental status), determine contribution to behavioral [illegible], to treat pt (patient), so aggression abates, assed in rounds 7 days/wk (week)." Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The interventions to be provided by social work were: "Individual therapy will be offered to child a minimum of 2 times per week to focus on aggressive behaviors and developing positive coping skills. Family therapy will be offered one time per week to educate family on mental status. Group therapy will be offered 5 times per week to rotate cluster group topics in an individualized format...group therapy will be offered a minimum of 3 times weekly and individual a minimum of 1 time weekly."

7. Patient 14: Admitted 6/22/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. No APRN interventions were listed. Pre-printed nursing modalities stated, "implement level of observation as ordered," "encourage nursing groups as assigned," "provide medication teaching twice weekly," "encourage to develop and utilize positive coping skills," "provide positive feedback for utilizing positive coping skills," and "complete room and clothing searches as warranted." The only interventions to be provided by social work were: "Ind. (individual) therapy will be offered 2x (times) per week to focus on SI (suicidal ideation)/SIB (self injurious behavior). Family therapy will be offered 1x per week to [increase] comm (communication). Group therapy will be offered 2x per week to rotate cluster group topics in individualized format."

B Interviews

1. During an interview with NP (Nurse Practitioner) 1, SW (Social Worker)1, SW 2, RN (Registered Nurse)1, Director of Social Work, Director or Activities Therapy, RT (Recreational Therapist)1, School Principal, and DON (Director of Nursing) on 7/9/13 at 9:30 a.m., they acknowledged that interventions of the treatment plans were generic and not specific to the needs of the patients.

2. During an interview with the Medical Director on 7/9/13 at 2:30 p.m., he agreed that all treatment plan interventions were generic and not specific to patient needs.

Based on interview and document review, the facility failed to ensure that 4 of 8 active sample patients (7, 9, 11, and 13) and 9 discharged patients, including sample Patient D6, were hospitalized based on the need for acute inpatient treatment. Four of 8 active sample patients (7, 9, 11, and 13) who did not require acute inpatient treatment were admitted to the "Behavioral Health Behavior Analysis Unit" (BAU), a subacute unit which the facility includes as an inpatient unit. Patients were admitted for extended periods of time to the BAU program for containment and the provision of behavioral interventions to develop the individual's social and living skills. In addition, 9 discharged patients over the previous year, including sample Patient D6, were admitted to the acute inpatient unit on "Respite" status. Patients admitted on "Respite" status received outpatient treatment after admission to the acute inpatient unit. This results in patients who do not require acute inpatient treatment being hospitalized for containment and behavioral interventions or for the provision of outpatient services.

Findings include:

I. Behavioral Health Behavior Analysis Unit (BAU)

A. Document review

The program description for the "Behavioral Health Analysis Unit" stated that "the format consists of a highly structured behavioral modification program" and "a behavioral analyst will work with Hospital staff and therapeutic services to create individualized behavior modification plans and strategies." The BAU "may be defined as a program whose primary goal is to provide opportunities for growth and healing of the individual and family." The "Behavioral Health Behavioral Analysis Unit Program strives to develop the individual's social and living skills with the goal of attaining successful transition into the community." The "Behavioral Health Behavioral Analysis Unit Program supports the use of reinforcers to modify behaviors. Reinforcement strengthens a behavior, either appropriate or inappropriate, and can be either the presentation of a positive stimulus or the removal of an aversive stimulus."

B. Staff Interviews

1. During an interview with Nurse Practitioner 1 on 7/9/13 at 10:30 a.m., he stated that patients in BAU programming were often stabilized on psychiatric medications and required infrequent adjustments. He stated that sample Patients 7, 9, 11, and 13 were stable on their psychiatric medications at that time and only required minor adjustments.

2. During an interview with the Director of Nursing (DON) on 7/9/13 at 1:30 p.m., she stated that patients in BAU programming received behavioral treatments implemented by Assistant Behavioral Associate - Line Therapists. She stated that the implementation of the behavioral plans was not supervised by nursing staff. She stated that patients in the BAU program "don't do well on acute care units." She stated that "the needs on the acute care side are different." She stated that "the acute care kids come and go" and "are disruptive to the BAU" patients. She stated that the "acuity" of the patients in the BAU program was not as "high" as the acute patients in that they did not need frequent assessments or medication adjustments.

2. During an interview with the Medical Director on 7/9/13 at 2:30 p.m., he stated that patients in BAU programming "wouldn't meet managed care criteria for admission" for acute psychiatric care. He stated that patients in BAU programming "wouldn't meet criteria to be in [an acute psychiatric] hospital" and several of the current BAU patients "wouldn't meet criteria to stay in the hospital." He stated the BAU program was "really a social program" and that medical oversight was not provided except as needed to support the behavioral programming. When asked the difference between the care being provided for inpatients in the BAU and a Psychiatric Residential Treatment Facility (PRTF), he stated that the only difference was that the doors were locked on the inpatient unit but not in the PRTF facilities.

II. Respite

A. Medical Record Review

Patient D6 was admitted on 4/26/13 on "Respite" status and discharged on 5/1/13. A review of medical record revealed no psychiatric evaluation or discharge summary was performed.

B. Document reviews

1. The program description for the "Children's Crisis Respite" (CCR) stated that "the purpose of the program is provide (sic) services to a child in the therapeutic milieu and provide the child's family respite for up to 5 days so that will able (sic) to effectively accept clinical intervention." The "Criteria for admission to CCR" included "Child does not meet criteria for acute hospitalization." The only "Physician Services" provided was "The child will be seen for medication management the first day he/she is in the CCR. " The "Therapy Services" were "Outpatient [staff] will provide individual, family, and collateral therapy. Inpatient Social Services Department will provide group therapy."

2. A review of the Medicare/Medicaid Psychiatric Hospital Survey Data form (CMS-724 (9/94)) completed by the facility summarizing data relative to hospital characteristics, types of services provided by the hospital, and hospital statistics, indicated that 9 patients had been admitted on "Respite" status between July 1, 2012 and June 30, 2013.

C. Staff Interviews

1. During an interview with psychiatric NP 1 on 7/8/13 at 10:30 a.m., he stated that patients who were admitted on "Respite" status were "like outpatients." He stated that the treatment for these patients was "not as intensive." He stated that he managed the psychiatric medications for these patients "more like outpatients."

2. During an interview with the Medical Director on 7/8/13 at 2:30 p.m., he stated that "Respite" patients were not considered inpatients although they were admitted to the acute inpatient unit. He stated that services were received and billed as outpatient treatment.

3. During an interview with SW 1 on 7/8/13 at 3:30 p.m., she stated patients who where admitted to "Respite" care didn't meet criteria for acute psychiatric inpatient admission.

4. During an interview with the facility Administrator on 7/10/13 at 9:15 a.m., she acknowledged that 9 patients were admitted on "Respite" status between July 1, 2012 and June 30, 2013.

Based on record review and staff interview, the facility failed to ensure that the discharge summary for 1 of 6 sample discharged patients (D6) was completed. This deficiency can result in failure to communicate the final diagnosis, discharge medications, course of treatment, summary of relevant labs and testing, and the discharge plan to outpatient providers.

Findings include:

A. Record Review

Patient D6 was admitted on 4/26/13 on "Respite" status and discharged on 5/1/13. No discharge summary was completed for this patient as of 7/9/13.

B. Staff Interview

During an interview with the Medical Director on 7/8/13 at 2:30 p.m., he stated that "Respite" patients were not considered inpatients although they were admitted to the acute inpatient unit. He acknowledged that discharge summaries were not completed for "Respite" status patients.

Based on interview and document review, the Medical Director failed to provide adequate medical oversight to ensure quality medical services. Specifically, the Medical Director failed to:

I. Ensure a complete psychiatric evaluation for 1 of 1 discharged patient (D6). This resulted in no current comprehensive psychiatric assessment to justify the diagnosis, to plan and oversee treatment, and to assess patient response to treatment. (Refer to B110)

II. Ensure complete psychiatric evaluations within 60 hours of admission for 4 of 8 active sample patients (1, 2, 10 and 11). The absence of a comprehensive psychiatric assessment completed within 60 hours hampered staff's ability to direct treatment, and delineate risk factors and strengths for patients' treatment plans and a failure to substantiate the diagnoses. (Refer to B111)

III. Ensure the development of Master Treatment Plans that identified psychiatric interventions, provided by the Advanced Practice Registered Nurse (APRN), to address the specific treatment needs of 7 of 8 active sample patients (1, 2, 7, 9, 10, 13, and 14). Many of the interventions on the MTPs were generic pre-printed interventions not linked to specific goals. Failure to clearly describe specific modalities on patients' MTPs may hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review

1. Patient 1: Admitted on 5/7/13 with MTP dated 5/8/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The Advanced Practice Registered Nurse (APRN) intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants."

2. Patient 2: Admitted on 6/28/13 with MTP dated 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants."

3. Patient 7: Admitted 12/12/12 with MTP update on 6/28/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants."

4. Patient 9: Admitted 4/9/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants."

5. Patient 10: Admitted 7/2/13 with MTP updated 7/11/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will assess needs and behaviors, will clarify mental status and make psychopharmacological adjustments as behavior warrants."

6. Patient 13: Admitted 3/25/13 with MTP updated 6/18/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The APRN intervention stated, "Will clarify M.S. (mental status), determine contribution to behavioral [illegible], to treat pt (patient), so aggression abates, assed in rounds 7 days/wk (week)."

7. Patient 14: Admitted 6/22/13 with MTP update on 7/1/13. No APRN interventions were listed.

B Interviews

1. During an interview with NP 1 on 7/9/13 at 10:30 a.m., he acknowledged that the psychiatric nurse practitioner's interventions on treatment plans were generic and not specific to patient needs.

2. During an interview with the Medical Director on 7/9/13 at 2:30 p.m., he agreed that all treatment plan interventions were generic and not specific to patient needs.

IV. Ensure that 4 of 8 active sample patients (7, 9, 11, and 13) and 9 discharged patients, including sample Patient D6, were hospitalized based on the need for acute inpatient treatment. Four of 8 active sample patients (7, 9, 11, and 13) who did not require acute inpatient treatment were admitted to the "Behavioral Health Behavior Analysis Unit" (BAU), a sub-acute unit which the facility includes as an inpatient unit. In addition, 9 discharged patients over the previous year, including Patient D6, were admitted to the acute inpatient unit on "Respite" status. Patients were admitted for extended periods of time to the BAU program for containment and the provision of behavioral interventions. Patients admitted on "Respite" status received outpatient treatment after admission to the acute inpatient unit. This results in patients who do not require acute inpatient treatment being hospitalized for containment and behavioral interventions or for the provision of outpatient services. (Refer to 125)

V. Ensure that the discharge summary for 1 of 6 patients (D6) was completed. This deficiency can result in failure to communicate the final diagnosis, discharge medications, course of treatment, summary of relevant labs and testing, and the discharge plan to outpatient providers. (Refer to B133)

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

I. Ensure confidentiality of patient records and
II. Ensure that, in 7of the 8 active sample records (1, 2, 7, 9, 10, 13 and 14), nursing interventions listed under master treatment plans were written in specific measurable terms. Failure to evaluate and document these interventions may hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

I. Confidentiality of Records: BAU Nursing Station

A. Observation

On 7/8/13 @ 1:15 p.m. the surveyor observed 5 patient charts lying on the counter of an open nursing station. The half door entrance was unlocked and no staff was in the nursing station. The surveyor walked into the nursing station and was easily able to pick up a chart and read it, unchallenged.

B. Interview

On 7/8/13 @ 1:25 p. m. the surveyor discussed the unattended charts with RN #2. This RN agreed this could jeopardize patient confidentiality.

On 7/9/13 @ 1 p.m. during an interview with the DON, she acknowledged the unattended charts posed a threat to patient confidentiality.

II. Generic Nursing Treatment Modalities

A. Record Review

1. Patient 1: Admitted on 5/7/13 with MTP dated 5/8/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

2. Patient 2: Admitted on 6/28/13 with MTP dated 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

3. Patient 7: Admitted 12/12/12 with MTP update on 6/28/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

4. Patient 9: Admitted 4/9/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

5. Patient 10: Admitted 7/2/13 with MTP updated 7/11/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

6. Patient 13: Admitted 3/25/13 with MTP updated 6/18/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills" and "complete room and clothing searches as warranted."

7. Patient 14: Admitted 6/22/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature.
Pre-printed nursing modalities stated, "implement level of observation as ordered", "encourage nursing groups as assigned", "provide medication teaching twice weekly", "encourage to develop and utilize positive coping skills", "provide positive feedback for utilizing positive coping skills", and "complete room and clothing searches as warranted."

B. Interview

In an interview with the DON on 7/9/13 at approximately 1:15 PM., the DON acknowledged many of the treatment modalities were generic in nature and thus were not specific to identified patient treatment issues.

Based on record reviews and interview the Social Work Director failed to:

I. Assure social work staff provided social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues and conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for 8 of 8 sample patients (1, 2, 7, 9, 10, 11, 13, and 14). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure the development of Master Treatment Plans that identified social work interventions to address the specific treatment needs of 7 of 8 active sample patients (1, 2, 7, 9, 10, 13, and 14). The social work interventions were stated as generic role functions. The absence of individualized interventions on master treatment plans potentially hampers the staff's ability to provide individualized care to patients.

Findings include:

A. Record Review

1. Patient 1: Admitted on 5/7/13 with MTP dated 5/8/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Individual therapy will be offered a minimum of 2 times per week to focus on SI (suicidal ideation). Family therapy will be offered one time per week to increase communication. Group therapy will be offered a minimum of 2 times per week to rotate cluster group topics in an individualized format."

2. Patient 2: Admitted on 6/28/13 with MTP dated 7/1/13. No interventions to be provided by social work were included on the treatment plan.

3. Patient 7: Admitted 12/12/12 with MTP update on 6/28/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Individual therapy will be offered a minimum of two times weekly. Family therapy will be offered a minimum of one time weekly to open communication among [the facility], [social services], and [Patient 7]. Group therapy will be offered 5 times weekly to address cluster specific topics."

4. Patient 9: Admitted 4/9/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Individual therapy will be offered to [Patient 9] a minimum of 2 times in order address -[(sic] SI (suicidal ideation) with plan and aggression l/t (leading to) HI (homicidal ideation). Family therapy will be offered a minimum of one time per week to enable open family communication. Group therapy will be offered a minimum of 5 times weekly, focusing on cluster-specific topics."

5. Patient 10: Admitted 7/2/13 with MTP updated 7/11/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Ind. (individual) therapy will be offered 2x (times) per week to focus on agg (aggression). Family therapy will be offered 1x per week to [increase] communication. Group therapy will be offered 2x per week to rotate cluster group topics."

6. Patient 13: Admitted 3/25/13 with MTP updated 6/18/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Individual therapy will be offered to child a minimum of 2 times per week to focus on aggressive behaviors and developing positive coping skills. Family therapy will be offered one time per week to educate family on mental status. Group therapy will be offered 5 times per week to rotate cluster group topics in an individualized format....group therapy will be offered a minimum of 3 times weekly and individual a minimum of 1 time weekly."

7. Patient 14: Admitted 6/22/13 with MTP update on 7/1/13. Treatment modalities were not linked to specific treatment goals and were generic in nature. The interventions to be provided by social work were: "Ind. (individual) therapy will be offered 2x (times) per week to focus on SI (suicidal ideation)/SIB (self injurious behavior). Family therapy will be offered 1x per week to [increase] comm (communication). Group therapy will be offered 2x per week to rotate cluster group topics in individualized format."

B. Interview

During an interview with the Director of Social Work on 7/9/13 at 12:30 p.m., she agreed that Social Workers' interventions on treatment plans were generic and did not address each specific patient's treatment needs.