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Based on interview and document review the facility failed to report allegations/incidents of abuse to the appropriate agencies in accordance with State and Federal Laws resulting in the potential for ongoing and uninvestigated abuse. Findings include:

On 09/28/2015 at 0830 during review of the complaint and grievance log a entry for 9/18/2015 recorded the "Nature of complaint/grievance: Abuse." Further comments documented: "a male staff member used unnecessary force in a physical management. Interviewed one patient, two RN's, four PCSs (patient care specialist), one scheduling coordinator. Additionally, video surveillance was reviewed. Allegation substantiated. Disciplinary action."

Further review of documents provided by the recipients rights officer/risk manager, staff H on 09/29/2015 at 1000 included eyewitness statements and documentation of the video footage for the incident on 09/18/2015. The eyewitness accounts documented, "Staff H was asked if the incident was reported to the local law enforcement or the Department of Human Services, Child and Adult Protective Services, he stated, "no."

On 9/29/2015 at 1400 the complete investigative file, medical record for patient #28, and the employee file for staff Q was reviewed. Based on documentation in the investigative file, staff Q "lifted patient #28 by the neck and threw him down face first into the bed with excessive force." The patient, #28 "complained of pain in his face." In the employee file the document titled, "Disciplinary action" dated 09/22/2015 revealed that staff Q was "terminated" based on the results of the investigation."

On 8/27/2015 at 0900 during review of the document titled, "Identifying and Reporting Abuse and Neglect" #RR-I006/ADM-I-003 revision date 12/14 on page 3 of 10, "III. Reporting Procedures:..O. The following action is taken if any staff member, by verbal allegation or personal observation, identifies or suspects patient abuse, neglect, or exploitation: .......4. The staff makes a verbal report to local law enforcement and the department of human services, child and protective services........, within 24 hours when there is reasonable allegation of criminal abuse."

Based on document review and interview, the facility failed to ensure that the medical record was legible, complete, dated and timed for 3 of 7 patients' medical records reviewed (#9, #30, & #32 ) resulting in the potential for unmet patient needs. Findings include:

On 09/28/2015 at 1100 during the tour of the facility, the medical record for patient #9 revealed that the psychiatrist progress notes for 9/25/15 & 9/26/15 did not include a time when the document was signed (a line is provided on the bottom of the document for signature, date & time).

On 09/28/2015 at 1115 staff F was interviewed about psychiatrist progress notes being untimed, she stated, "I can see that they forgot to time their notes."

On 09/29/2015 at 1400 the policy titled, "Documentation Standards" #HIS-VI-001 dated revised 12/96 on page 1 of 2 stated, "III...B. All entries shall contain the date and time recorded."


32164

On 9/29/15 at 1304 review of patient #30's medical record revealed 19/22 psychiatrist's progress notes did not include a time when the document was signed (a line is provided on the bottom of the document for signature, date & time).

On 9/2915 at 1400 review of patient #32's medical record revealed 5/13 psychiatrist's progress notes did not include a time when the document was signed.

On 9/30/15 at 1045 during an interview with staff A and O these findings were confirmed. Staff A stated, "Yes, this is something we have discussed with medical staff and are making changes going forward."

Based on document review and interview, the facility failed to ensure that all orders in the medical record were legible, complete, dated and timed for 3 of 8 patients reviewed (#27, #30, & #32 ) resulting in the potential for unmet patient needs. Findings include:

On 9/28/15 at 1130 review of patient #27's medical record revealed five telephone orders dated between 9/18/15 and 9/21/15 that did not have a time documented in the designated space provided for the authenticating physician. On 9/28/15 at 1130 staff M confirmed these findings and she was queried as to the facility's policy on telephone orders. Staff M stated, "They (telephone orders) should be signed, dated, and timed within 48 hours."

On 9/29/15 at 1304 review of patient #30's medical record revealed two telephone orders dated 6/4/15 that did not have a time documented in the designated space provided for the authenticating physician.

On 9/29/15 at 1400 review of patient #32's medical record revealed one telephone order dated 6/30/15 that did not have a legible time documented in the designated space provided for the authenticating physician.

On 9/30/15 at 0830 review of the document titled, "Policy: NSG-V-031, Transcribing and Noting Physician Orders" revision date 9/09 revealed on page 1 "1. Physician orders: a. will be dated, timed, and signed by the physician; b. will be legibly written; c. given verbally or by telephone to a Registered Nurse or Pharmacist and be signed by the physician within 48 hours..."

On 9/30/15 at 1045 during an interview with staff A and O regarding the findings for patients #30 & #32 were confirmed. Staff A stated, "Yes, this is something we have discussed with medical staff and are making changes going forward."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated September 30, 2015.

K-0018
K-0025
K-0027
K-0029
K-0047
K-0052
K-0144
K-0147

Based upon observation and interview the facility failed to maintain the hospital environment to ensure a safe and sanitary environment resulting in the potential for transmission of infectious agents to all patients served by the facility.

Findings include:
On 9/28/15 at approximately 1045, the drain line for the kitchen walk-in cooler condenser was observed below the rim of the receiving drain, without the required air gap of at least 1 inch of unobstructed space.

On 9/28/15 at approximately 1130, the housekeeping closet near the entrance was observed to have a Y-valve with shut offs connected to the mop sink faucet. These shut offs are located downstream from the built in atmospheric vacuum breaker (AVB), subjecting the AVB to constant pressure, which it is not approved for.
On 9/28/15 at approximately 1155 the janitor's closet within the A Unit (adjacent to room 116) was observed to have a chemical dispensing system properly connected to the mop sink faucet via a wasting tee (aka "Side Kick") however, the built in AVB and cold water line and handle were warm to the touch, indicating the AVB had already failed and was permitting hot water to leach into the cold water loop.

On 9/28/15 between approximately 1030 and 1300, the following areas were observed with dust accumulation: sloped tops of cabinets in all patient rooms, clean utility rooms, day rooms and pantries throughout the facility, and tops of cabinets in the Pharmacy.

Based upon observation and interview the facility failed to provide a sanitary environment in the kitchen and in patient care units in a manner to prevent the transmission of foodborne and vectorborne communicable diseases. This deficient practice could potentially effect all inpatients, partial hospital program patients, and staff or visitors that consume food prepared from the kitchen.

Findings include:
On 9/28/15 at approximately 1050, the following potentially hazardous food (PHF) items were observed in a 2-door reach in cooler without discard dates: a tray of sliced tomatoes, a prepared cold cut sandwich, spaghetti and meatballs and cottage cheese. Staff P was unaware of when these items had been prepared, and all items were discarded by Staff P at the time of the survey.

On 9/28/15 at approximately 1105, a dietary employee in the cafeteria area was observed handling soiled dishware, followed by a broom and dustpan while wearing single use gloves. The employee then discarded the gloves, and began donning a new pair of single use gloves without washing hands. Staff P confirmed that hands must be washed in between glove changes.

On 9/28/15 at approximately 1110, the slicer in the kitchen was observed not in use with an accumulation of dried food debris on the areas underneath the blade and protective cover. An employee stated that the slicer had last been used on Saturday (9/26/15). Staff P confirmed that the slicer was not properly cleaned.
On 9/28/15 at approximately 1200, whole fruit such as apples, oranges and bananas and pre-packaged single servings of crackers were observed stored in a cardboard box in a day room on the A unit. On 9/28/15 at approximately 1215 at the nurse station on the D Unit, whole fruit and crackers were observed stored in a wicker basket with a hard plastic lining with a rough cut edge and also whole fruits in a cardboard box for service to patients.

On 9/28/15 at approximately 1215, at the nurse station on the E Unit, an employee was observed dispensing ice from a beverage cooler for a patient. The cooler contained a Styrofoam cup to be used for dispensing the ice. The employee was observed to dispense the ice without performing hand hygiene prior to handling the cup.

On 9/28/15 at approximately 1220 a single serving carton of milk was observed in the cabinet beneath the handwash sink at the pantry area of the day room on the E Unit. This carton had been opened, and was observed to have a printed on manufacturer's discard date of 9/13/15. The container of milk was warm to the touch. Staff D confirmed these findings and stated that housekeeping staff is supposed to be cleaning in the cabinets daily.

On 9/28/15 at approximately 1220 a prepared cold cut sandwich was observed in the pantry refrigerator of the E Unit with no discard date. The temperature monitoring log at this refrigerator was observed to have a most recent entry date of 9/22/15.

On 9/28/15 at the times noted, drain flies (aka fruit flies) were observed in the following locations: kitchen dishwashing area (1100); cafeteria serving line adjacent to the handsink (1115); C-2 Unit nurse station (1130). Staff D witnessed these observations and stated that the facility has a pest control contract but was unaware of any treatment for drain or fruit flies.

On 9/28/15 between approximately 1030 and 1230, the following items were observed stored on the floor: patient belongings in the storage closet for beds 226-231 on C unit; boxes of paper products and Styrofoam cups in the D unit day room; box of Styrofoam cups in E unit pantry.

On 9/28/15 at approximately 1245, employee coats were observed stored on shelving above food items in the basement kitchen storage room.

Based on observation, interview, and record review, the facility failed to:


I. Ensure that complete and legible psychiatric assessments were documented for eight (8) of 10 sample patients (A1, B1, B2, C1, C2, D1, D2 and F1). Assessments were either handwritten on a template which lacked specificity and individualization, or dictated in a manner which omitted key features of a complete and thorough psychiatric evaluation. These deficiencies create incomplete assessments potentially resulting in inadequate treatment and protracted hospital stays. (Refer to B110)

II. Provide comprehensive Master Treatment Plans that reflected appropriate active treatment to be given to patients and provided by the facility staff. Specifically, the facility failed to provide comprehensive Master Treatment Plans (MTPs) that were individualized with all necessary components to provide active treatment. The MTPs were missing the following components:

A. Individualized short-term goals in observable and behavioral terms for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). The goals were not specific and/or described routine hospital functions, which did not define areas of patient improvement related to reasons for hospitalization. (Refer to B121)

B. Individualized and specific active treatment interventions for eight (8) of eight (8) active sample patients (A5, A6, A10, A13, B4, B6, B7 and B15). (Refer to B122)

Failure to develop master treatment plans with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patients' active treatment needs not being met.

III. Ensure that psychiatric progress notes adequately and relevantly measured individualized progress toward stated goals in the patient's treatment plan for six (6) of 10 sample patients (B1, B2, C1, C2, C3 and D2). Entries often reflected brief observations and failed to indicate how well the patient was responding to treatment and progressing toward set goals. Additionally, multiple signed notes contained blank spaces where transcription was not complete. These deficiencies lead to care which is not appropriately recorded, potentially protracting hospital stays and/or causing the potential for medical error. (Refer to B126)

Based upon record review, document review, and interview, the facility failed to ensure that complete and legible psychiatric assessments were documented for 8 of 10 sample patients (A1, B1, B2, C1, C2, D1, D2 and F1). Assessments were either handwritten on a template which lacked specificity and individualization, or dictated in a manner which omitted key features of a complete and thorough psychiatric evaluation. These deficiencies create incomplete assessments potentially resulting in inadequate treatment and protracted hospital stays.

Findings include:

A. Record Review

1. Patient A1 was admitted on 8/1/2015 with a diagnosis of "Persistent Depressive D.O. [Disorder], r/o [rule out] MDD [Manic Depressive Disorder], r/o ODD [Oppositional Defiant Disorder]." A psychiatric assessment was completed on that same date using the facility's handwritten form: "Psychiatrist Evaluation/Admission History and Examination." The section titled: "Initial Plan of Care" contained words which appear to read: "Therapist with one (1) psychiatric session" without any further descriptions of specific interventions which would be employed and did not tie these modalities to an individualized assessment of the patient's needs.

2. Patient B1 was admitted 8/13/2015 with a diagnosis of "Schizophrenia, chronic, undifferentiated type, Schizoaffective disorder, and Alcohol and prior cannabis abuse." The Psychiatric Intake Evaluation dated 8/13/2015 contained multiple sections which were blank or insufficiently completed. Specifically, sections titled "Social History" and "Family History" were left blank. "Mental Status Examination" contained only the following entries: " Attitude/Behavior: Patient is floridly psychotic and uncooperative markedly;" "Judgment: Very poor;" "Insight: Very poor." "She is markedly floridly psychotic. We are unable to obtain much information and she is not allowing the mental status, severely psychotic, responding to internal stimuli, actively delusional." A handwritten note (which was neither dated/timed nor signed) was added indicating "highly uncooperative, won't participate in interview process." The following sections were blank: "Motor Activity," "Affect," "Mood," "Speech/Language," "Thought Process," "Thought Content," "Perception," "Orientation," "Concentration/Attention Span," "Recent Memory," "Remote Memory," "Abstract Reasoning," and "Intelligence." Under "Patient Assets" the following was noted: "At this time, patient is floridly psychotic and unable to provide much information and unable to ascertain any strengths at this time." The section "Patient Limitations" was blank.

3. Patient B2 was admitted 7/30/2015 with a diagnosis of "Schizophrenia, chronic, undifferentiated type, Schizoaffective disorder." The Psychiatric Intake Evaluation dated 7/31/2015 contained the following sections which were blank: "Functional Assessment," "Current Medications," "Mood," "Initial Discharge Plan," "Prognosis."

4. Patient C1 was admitted 8/14/15 with a diagnosis of "Schizoaffective-bipolar." A psychiatric assessment was completed on 8/15/2015 using the facility's handwritten form: "Psychiatrist Evaluation/Admission History and Examination." Though largely complete, most of the handwritten sections were illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the section titled: "Chief Complaint (Pt's [Patient's] own words)/ History of Present Illness (Onset of illness and circumstances leading to admission)" was completed using a series of observations about the patient's current behaviors: "easily agitated, kept playing with [his/her] hair," as well as selected quotes: "I have small brain." The section lacks any mention of illness onset or circumstances leading to admission despite cues contained in the form's header. The section titled: "Drug/Alcohol Abuse History" had no entry pertinent to this header. The "Initial Plan of Care" section only listed "Meds, group, Education" without any further description of which specific interventions would be employed and did not tie these modalities to an individualized assessment of the patient's needs.

5. Patient C2 was admitted 8/2/15 with a diagnosis of "Bipolar, Type II." A psychiatric assessment was completed using the facility's handwritten form "Psychiatrist Evaluation/Admission History and Examination" on that same date. Handwritten sections were generally illegible and too succinct to provide the depth of information required in a formal psychiatric evaluation. Specifically, the section titled: "Chief Complaint (Pt's [Patient's] own words)/ History of Present Illness (Onset of illness and circumstances leading to admission)" were largely illegible but did indicate that the patient was released from the facility on 7/28/2015. Despite this apparent recent data source, the section titled: "Drug/Alcohol Abuse History" was completed by the words "not answering" and three additional words which were illegible. The sections for "Medical History," and "Allergies" were both filled in with "Unknown." The section titled: "Initial Plan of Care" contained four words which were illegible.

6. Patient D1 was admitted 7/21/2015 with a diagnosis of "Schizoaffective disorder, Bipolar type." A psychiatric assessment was completed using the facility's handwritten form "Psychiatrist Evaluation/Admission History and Examination" on 7/22/2015. Under the section titled: "Initial Plan of Care," the psychiatrist recorded: "1. (Illegible) safely. 2. (Blank)"

7. Patient D2 was admitted 8/7/2015 with a diagnosis of "Major depressive D.O. [Disorder], recurrent with psychosis." A psychiatric assessment was completed using the facility's handwritten form "Psychiatrist Evaluation/Admission History and Examination" on 8/8/2015. The section titled: "Family History" was blank. The section titled: "Initial Plan of Care" listed "Meds, Groups, Milieu, Education" but failed to further specify these interventions or link them to the patient's individually assessed needs.

8. Patient F1 was admitted 8/9/2015 with a diagnosis of "Bipolar I, mixed, Polysubstance dependence." A psychiatric assessment was completed on 8/10/2015 using the facility's handwritten form: "Psychiatrist Evaluation/Admission History and Examination." The section titled: "Initial Plan of Care" listed "Inpt. [Inpatient] tx [treatment], stabilize mood, prevent harm" but failed to further specify these interventions or link them to the patient's individually assessed needs.

B. Document Review

1. The facility's "Policy #HIS-VI-00" titled "Documentation Standards" stated: "G. The usefulness of the record depends in part on the legibility. Licensing agencies all require and necessitate a legible record. If economical or feasible medical entries should be typed. Staff who have difficulty writing legibly should print their entries."

2. A review of minutes of the Performance Improvement Committee from the January 20, 2015 meeting of the Performance Improvement Committee, pages 8-9 of 11, reviewed adherence to documentation guidelines as per the facility's policies and stated, "Areas of concern include...Physician Psych Eval [Evaluation] - All Sections Completed at 21% compliance."

C. Staff Interviews

1. In an interview with the D.O.N. on unit C1 on 8/18/2015, she acknowledged being unable to read the intake assessment for patient C1. She stated, "It is a problem."

2. In an interview with the Medical Director on 8/18/2015, he acknowledged that sections of the "Psychiatrist Evaluation/Admission History and Examination" form were incomplete for multiple sampled patients but stated that these sections were not necessary as "other disciplines" can gather this information.

Based on record review and interview, the facility failed to provide master treatment plans that identified individualized short-term goals in observable and behavioral terms for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). The goals were not specific and/or described routine hospital functions, which did not define areas of patient improvement. Goal statements failed to give specific focus to treatment, potentially leading to fragmentation of care.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (8/3/15), A2 (8/4/15), B1 (8/14/15), B2 (7/31/15), C1 (8/17/15), C2 (8/4/15), C3 (8/3/15), D1 (7/23/15, D2 (8/12/15) and F1 (8/11/15). This review revealed the following deficiencies for psychiatric problems.

1. Patients A1 had the following short-term goals (STG) that were not behaviorally specific for the problem of "Depression with Suicidal Ideations."

a. "[Patient name] will report any suicidal thoughts/impulses to staff prior to acting on them." This short-term goal stated staff expectations to maintain patient safety however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the suicidal thoughts/impulses. The STG was not stated in behavioral terms reflecting what the patient would be doing or saying to reduce suicidal thoughts/impulses, such as stating s/he has a plan for the future, know non-harmful alternatives, etc.

b. "[Patient's name] will not self harm for three (3) consecutive days prior to DC [discharge]." The STG was not stated in behavioral and specific with positive alternative or replacement behavior(s) that would show the patient's increased level of functioning.

c. "[Patient's name] will comply [with] medication regimen while in the hospital." This STG was a staff expectation and was not written as a patient oriented goal related that included the patient's action statement regarding his/her understanding about medications (benefits, side effects) and reasons for compliance.

2. Patient A2 had the following short-term goal that was not behaviorally specific for the problem of "Depression with Suicidal Ideations." "[Patient's name] will not self harm for three (3) consecutive days prior to DC [discharge]." The STG was not stated in behavioral and specific terms with positive alternative or replacement behavior that would show the patient's increased level of functioning.

3. Patient B1 had the following short-term goal that was not behaviorally specific for the problem of "Psychotic Behavior..." - "[Patient's name] will take medications willingly." This STG was a staff expectation not written as a patient oriented goal that included the patient's action statement regarding his/her understanding about medications (benefits, side effects) and reasons for compliance.

4. Patient B2 had the following short-term goals that were not behaviorally specific for the problem of "Psychotic Behaviors..."

a. "[Patient's name] will willingly take Zoloft, Seroquel, Haldol, and Depakote." This STG was a staff expectation and was not written as a patient oriented goal that included the patient's action statement regarding his/her understanding about medications (benefits, side effects) and reasons for compliance.

b. "[Patient's name] will sign release of information for member/support person. This STG was a staff expectation and a routine hospital function.

5. Patient C1 had the following short-term goals that were not observable and behaviorally specific for the problem of "Alteration in Thought Process."

a. "[Patient's name] will report a 50% decrease in auditory and visual hallucinations for three (3) consecutive days." The MTP had no behavioral specific information documented regarding how Patient C1 specifically manifested auditory and visual hallucinations. Therefore, there was no behavioral description regarding the content of "Auditory and Visual Hallucinations" that provided the information necessary for staff to know what specific behaviors to observe.

b. "[Patient's name] will take Depakote ER, Invega, Klonopin willingly." This STG was a staff expectation was not written as a patient oriented goal that included the patient's action statement regarding his/her understanding about medications (benefits, side effects) and reasons for compliance.

c. "[Patient's name] will sign release of information for member/support person. This STG was a staff expectation and a routine hospital function.

6. Patients C2 had the following short-term goals that were not behaviorally specific for the problem of "Depression with Suicidal Ideations."

a. "[Patient name] will report any suicidal thoughts/impulses to staff prior to acting on them." This short-term goal was a staff expectation to maintain patient safety, however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the suicidal thoughts/impulses. The STG was not stated in behavioral terms reflecting what the patient would be doing or saying to reduce suicidal thoughts/impulses.

b. "[Patient's name] will verbalize no suicidal thoughts for three (3) consecutive days prior to DC [discharge]." The STG was not stated in behavioral and observable terms with positive alternative or replacement behavior that would show the patient's increased level of functioning. There was no specific behavioral description of "Suicidal thoughts" included on the MTP so that staff would know what to observe.

c. "[Patient's name] will identify any questions, concerns, or benefits to taking Lamictal." This STG did not add a patient's action statement regarding his/her understanding about Lamictal (benefits, side effects) and reasons for compliance.

7. Patient C3 had the following short-term goals that were not behaviorally specific for the problem of:

"Danger to Self..."

"[Patient name] will verbalize no suicidal thoughts or exhibit self-destructive behavior for three (3) consecutive days prior to discharge." This short-term goal stated staff expectations to maintain patient safety however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

"Psychotic Behavior..."

"[Patient's name] will take antipsychotic medication willingly." This STG was a staff expectation was not written as a patient oriented goal that included the patient's action statement regarding his/her understanding about medications (benefits, side effects) and reasons for compliance.

8. Patient D1 had the following short-term goal that was not behaviorally specific for the problems of:

a. "Psychotic Behaviors..." - "[Patient's name] will report that [s/he] is no longer experiencing severe paranoid/delusional thoughts that making [him/her] unable to function or a danger to himself and/or others for at least three (3) days prior to discharge." This short-term goal did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or reduce the paranoid/delusion behaviors, such as verbalizing s/he is able to function despite delusional thoughts.

b. "Aggressive Behaviors..." - "[Patient's name] will not exhibit any aggressive behaviors for at least two (2) consecutive days prior to discharge." This short-term goal stated did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or reduce the aggressive behaviors such as verbalizing what s/he will do instead of engaging in aggressive behavior and/or actually demonstrating non-harmful behavior when becoming angry.

9. Patient D2 had the following short-term goal that was not behaviorally specific for the problem of "...being non-compliant with medications and having increased suicidal ideations." - "[Patient's name] will take medication willingly." This was a staff expectation and was not written as a patient oriented goal that included direct positive action behavior(s) that the patient would achieve regarding non-compliance such as stating his/her understanding benefits of taking medications and/or actions to take when having problems with medications after discharge.

10. Patient F1 had the following short-term goals that were not behaviorally specific for the problem of:

a. "Suicidal Threats..." - STG: "Patient's name] will take medication willingly and report benefit/side effects to staff." This was a staff expectation and was not written as a patient oriented goal that included direct positive action behavior(s) that the patient would achieve regarding non-compliance such as stating his/her understanding of side effects of specific medication(s) and benefits of taking medications after discharge.

b. "[Patient's name] reports abusing alcohol..." - STG: "[Patient's name] will take medications as prescribed." This was a staff expectation not written as a patient oriented goal that included direct positive action behavior(s) that the patient would achieve regarding medication compliance.

B. Staff Interviews

1. During interview on 8/18/15 at 10:15 a.m., MTPs plans were reviewed with RN2. RN2 acknowledged that some short-term goals were global and staff expectations.

2. During interview on 8/19/15 at 10:00 a.m., MTPs plans were discussed with the Director of Social Work. She acknowledged that some goal statements were vague and staff expectations.

Based on record review and interview, the facility failed to develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplishment treatment goals for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). Specifically, Master Treatment Plans (MTPs): (1) included routine and generic discipline functions such as "assessing" "checking in," "encouraging" and "administering medications" written as active treatment interventions for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1); (2) failed to include a specific frequency of contact to ensure intensive active treatment. Instead, several interventions were listed to be implemented on an "as needed" or "PRN" basis instead of including a specific and scheduled frequency of contact to ensure the intensive required for active treatment for seven (7) of 10 active sample patients (A1, A2, B1, B2, C2, C3 and D1); and (3) failed to include a registered nurse (RN) lead medication group on the treatment plan that was listed on the group schedules and attended by eight (8) of 10 active sample patients (B1, B2, C1, C2, C3, D1, D2 and F1). These deficiencies potentially result in staff being unable to provide consistent and focus active treatment.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (8/3/15), A2 (8/4/15), B1 (8/14/15), B2 (7/31/15), C1 (8/17/15), C2 (8/4/15), C3 (8/3/15), D1 (7/23/15, D2 (8/12/15) and F1 (8/11/15). This review revealed the following deficiencies related to psychiatric problems on MTPs.

I. Failure to Include Individualized Interventions

A. Record Review

A review of medical records revealed the "Interdisciplinary Master Treatment Plans" contained the following routine and generic discipline functions written as interventions instead of individualized specific interventions to assist patients to accomplish treatment goals. Several statements, written as interventions, were identical or similarly worded despite different presenting symptoms and needs of each patient.

1. Patient A1's MTP contained the following routine and generic discipline functions for Problem #1 "Depression with Suicidal Ideations..."

SW Intervention - "Check-ins with [Patient's name] regarding mood, negative and suicidal thoughts, as well as significant behavioral changes in condition.

RN Intervention - "Conduct suicidal reassessments." "Administer medications as ordered & encourage compliance [with] medication."

2. Patient A2's MTP contained the following routine and generic discipline functions for Problem #1 "Depression/Danger to self."

RN Intervention - "Assess for SI [suicidal ideation] & monitor." "Assess medication responses and adjust medication as needed."

3. Patient B1's MTP contained the following routine and generic discipline functions for Problem #1 "Psychotic Behaviors."

RN Intervention - "Daily check-ins & use of coping skills."

SW Intervention - "Will encourage [his/her] to sign a release of information to allow staff to explore preceding events to admission, baseline level of functioning, discharge planning and treatment process." "Will schedule an aftercare appointment a referral for a CMH to allow [Patient's name] to continue services on an outpatient basis."

4. Patient B2's MTP contained the following routine and generic discipline functions for the following psychiatric problems:

Problem #1: "Psychotic Behaviors."

MD Intervention - "Assess medication response, side effects, and [sic adjustment as indicated."

SW Intervention - "Obtain information from family member/support person such as [Patient's name] baseline, relevant history and behavior prior to admission."

Problem #2: "Noncompliance of Medication or Treatment..."
RN Intervention - "Assess the patient's ability to recognize the need for treatment and the patient's understanding of his/her illness."

5. Patient C1's MTP contained the following routine and generic discipline functions for
Problem #1: "Alteration in Thought Process."

SW Intervention - "Check in with patient regarding presence of hallucinations. Provide Support as needed." "Contact [Patient's name] to obtain additional information..."

6. Patient C2's MTP contained the following routine and generic discipline functions for Problem #1: "Depression with Suicidal Ideation."

RN Intervention - "Assess [Patient's name] for S/I [suicidal ideation]."

SW Interventions - "Provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition." "Contact pt's [patient's] guardian, casemanger, and AFC staff to obtain additional information and discuss the tx [treatment] and discharge plan."

RT Intervention - There were no intervention identified for RT staff. "RT Group" was written in the frequency/duration section of the MTP but there was no specific intervention assigned based on the scope of service provided by recreational therapist.

7. Patient C3's MTP dated 8/3/15 contained the following routine and generic discipline functions for Problem #1 "Danger to self..."

RN & SW Intervention - "Assess pt [patient] for SI [suicidal ideation]."

SW Intervention - "Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition."

8. Patient D1's MTP contained the following routine and generic discipline functions for:

Problem #1: "Psychotic Behaviors," - RN Intervention: "Assess medication response, side effects, and make adjustment as indicated."

Problem #2 - "Aggressive Behaviors..." - SW Interventions: "Staff will encourage patient to utilize positive coping skills and healthy alternatives to aggressive behaviors for at least two (2) consecutive days prior to discharge." "Encourage patient to discuss any questions or concerns with [his/her] psychiatrist and/or charge nurse."

9. Patient D2's MTP contained the following routine and generic discipline functions for Problem #2: "Substance Abuse..."

MD Intervention - "[MD's name] will assess medication responses and adjust medication as needed."

10. Patient F1's MTP contained the following routine and generic discipline functions for:

Problem #1: "Suicidal Threats..."

RN Intervention - "Encourage use of safety crisis plan content to assist [with] success [with] after care tx [treatment]."

Problem #2: "...reports abusing alcohol..."

RN Intervention - "[MD's name] will assess medication responses and adjust medication as needed." [Note: Although it was not within the scope of practice for RNs to adjust medications, two RN's names were handwritten for this intervention on the MTP.] This identical or similarly worded intervention was also included on the MTPs of three (3) other active sample patients above (A2, D1, and D2).

B. Staff Interviews

1. During interview on 8/18/15 at 9:45 a.m., RN1 acknowledged that routine and generic nursing functions were listed as treatment interventions on the master treatment plan. RN3 agreed that intervention statements did not address the patient's presenting problems.

2. During interview on 8/18/10 at 3:15 p.m., the Director of Nursing acknowledged that statements on the treatment plan were written as routine and generic nursing functions rather than interventions to assist patients to meet their specific needs and accomplish treatment goals. She agreed that the RN's scope of practice did not allow adjustment of medications.

II. Failure to Include Scheduled Frequency of Contact for Interventions.

1. Patient A1

Problem a: "Depression with Suicidal Ideation."

RN Intervention - "Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment." The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

2. Patient A2

Problem a: "Depression/Danger to Self."

RN Intervention - "Educate [Patient's name] on the benefits of taking all prescribed medications as prescribed by psychiatrist their side effects, and the importance of medication compliance. The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

3. Patient B1

Problem: "Psychotic Behavior...."

RN & SW Intervention - "Educate patient on the benefits of taking medication, and the important of medication compliance." "Explore with [Patient's name] any concerns from the changes in medication." The only frequency listed was "When medication changes are made." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for active treatment interventions assigned on the MTP.

4. Patient B2

a. Problem: "Psychotic Behaviors..."

RN & SW Intervention - "Educate [Patient's name] on the benefits of taking medication and the important of medication compliance." The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

b. Problem: "ETOH [Alcohol]," "Opiates"

RN Intervention - "Explore the patient's understanding of their current need for hospitalization as it relates to the patient's alcohol/substance abuse." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

5. Patient C2

Problem a: "Depression with Suicidal Ideation."

SW Intervention - "Educate patient regarding symptoms of depression and importance of compliance with treatment." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

Problem b: "Alteration in Thought Process."

SW Intervention - "Educate patient on the benefits of taking medication and the importance of medication compliance. The frequency for this intervention was "Process Group."

SW and RN Intervention - "Explore with [Patient's name] any concerns or benefits from the changes in medication." The frequency was "PRN."

This type of frequency of contact listed for the above interventions failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

6. Patient C3

Problem: "Danger to self"

RN & SW Intervention - "Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment. There was no frequency listed for this intervention.

7. Patient D1

Problem: "Psychotic Behavior...."

SW Intervention - "Staff will encourage patient to utilize positive coping skills and healthy alternatives to aggressive behaviors for at least two (2) consecutive days prior to discharge." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for active treatment interventions assigned on the MTP.

B. Staff Interviews

1. During interview on 8/18/15 at 3:15 p.m., the Director of Nursing acknowledged that some intervention statements on the treatment plan did not include a regularly scheduled frequency of contact.

2. During interview on 8/19/15 at 10:00 a.m., the MTPs were reviews the Director of Social work acknowledged the frequency of contact was listed as PRN and some social work interventions were not scheduled to be conducted on a regular scheduled basis.

III. Failure to Include Groups Attended by Patients on the Master Treatment Plan

A. Document Review

1. A review of the facility's unit group schedule revealed that a RN led Medication Education Group was to be conducted on each Saturday on the Adult Psychiatric Units (B, C1, C2, D, and E/F). This group was not included on the MPTs for Patients B1, B2, C1, C2, C3, D1, D2, and F1.

2. A review of the "Group Notes" Form for each patient listed above revealed that these patients had attended at least one group and the medical record showed documentation of patient's non-attendance and in one case alternative one-to-one treatment provided.

B. Staff Interview

During interview on 8/18/15 at 3:15 p.m., the Director of Nursing admitted that the medication education Group assigned to RNs was not included on MTPs. She stated, "It should have been included. We are doing something that we are not getting credit for."

Based upon record review, document review, and interview, the facility failed to ensure that psychiatric progress notes adequately and relevantly measured individualized progress toward stated goals in the patient's treatment plan for six (6) of 10 sample patients (B1, B2, C1, C2, C3 and D2). Entries often reflected brief observations and failed to indicate how well the patient was responding to treatment and progressing toward set goals. Additionally, multiple signed notes contained blank spaces where transcription was not complete. These deficiencies lead to care which is not appropriately recorded, potentially protracting hospital stays and/or causing the potential for medical error.

Findings include:

A. Record Review

1. Patient B1 was admitted 8/13/2015 with a diagnosis of "Schizophrenia, chronic undifferentiated type, and Schizoaffective disorder." The "Psychiatrist Progress Note" dated 8/14/2015 under the section titled "Interval History/Clinical Status" noted: "a car accident past Sunday- paralyzed but released on the day. Spiritual awakening during the accident, to contact President and Michelle Obama." The section titled: "Diagnosis/Assessment" noted: "Psychotic. Poor insight. Grandiose." Though these statements reflected symptoms present on admission, no synthesis of this information indicating the patient's progress was included and the "Intervention/Plan" section stated only: "to cont [continue]the plan."

2. Patient B2 was admitted 7/30/2015 with a diagnosis of "Schizophrenia, chronic undifferentiated type, Schizoaffective disorder." Psychiatric progress note dated 8/3/2015 and signed by the psychiatrist contained two blanks between lines 7 and 9: "At this time, emergency protocol was given as patient has been refusing to take medicines, staying acutely psychotic and threatening_________. Haldol and Zyprexa back up for _______ And Depakote which [s/he] shall also get." Psychiatric progress note dated 8/4/2013 and signed by the psychiatrist contained 1 blank on line 5: "[S/he] has been talking to [himself/herself], bizarre, illogical and using a lot of foul language towards, approaching such as why don't you stop it and die bitch, etc. _____and other." Psychiatric progress note dated 8/6/2015 and signed by the psychiatrist contained a blank on line 10: "Sometimes it is not sure if [s/he] has been taking the medicines, and somewhat bizarre, illogical, hyper verbal, and very bizarre______ and talking to [himself/herself]." Psychiatric progress note dated 8/10/2015 and signed by the psychiatrist contained a blank on line 6: "If [s/he] is agreeable, [s/he] can refuse the Haldol D injection ______not taking various medications." Psychiatric progress note dated 8/11/2015 reported: "[S/he] continues to be markedly paranoid, delusional. DICTATION ENDS HERE." Handwritten in the margins: "Continue (illegible) treatment waiting for court hearing. Threatening staff."

3. Patient C1 was admitted 8/14/2015 with a diagnosis of "Schizoaffective-bipolar." "Psychiatrist Progress Note" dated 8/16/2015 in the section titled "Diagnosis/Assessment" noted: "Pt [Patient] very psychotic." In the section titled "Intervention/Plan" the entry stated, "Adjust meds as needed." On 8/17/2015, in the "Diagnosis/Assessment" section the psychiatrist recorded: "Pt. still psychotic," and in the "Intervention/Plan" section: "Keep meds same."

4. Patient C2 was admitted 8/2/2015 with a diagnosis of "Bipolar disorder, Type II." The psychiatric progress note dated 8/13/2015 and signed by the psychiatrist contained a blank on line 4: "Patient has not responded to treatment ______ limits and structure." The psychiatric progress note dated 8/14/2015 and signed by the psychiatrist contained a blank on line 4: "Patient is still bizarre. Still irrational and ______if patient agrees." The psychiatric progress note dated 8/15/2015 and signed by the psychiatrist contained two (2) blanks on line four (4): " S/he] had been seen by [MD's name], blood work was recommended by the psychiatrist (sic) and second opinion, so blood work was done, which seemed to be okay and so we will plan to discontinue Risperdal______ 100 mg twice a day for psychosis. [S/he] will ______medications."

5. Patient C3 was admitted 7/30/2015 with a diagnosis of "Psychosis NOS (not otherwise specified)" Two psychiatric progress notes for 8/15/2015 were contained in the medical record, both signed by the psychiatrist. The first contained a blank on line 2: "[S/he] is still very guarded. [S/he] is still ______. " The second contained a blank on line 2: "GOALS: Case discussed. Patient seen in absence of [MD's name]. Reviewed discharge. Discussed ______. Patient acutely psychotic. Very paranoid. Very delusional."

6. Patient D2 was admitted 8/7/2015 with a diagnosis of "Major depressive DO [disorder], recurrent, with psychosis." The psychiatric progress note dated 8/14/2015 and signed by the psychiatrist contained a blank on line 10: "Plan is to increase Seroquel to 200 mg at night and increase Lamictal to 25 mg twice a day, order ______ for constipation." The psychiatric progress note dated 8/16/2015 and signed by the psychiatrist contained a blank on line 4: "[His/her] medication was adjusted yesterday. Patient seemed really frightened and seemed to be______."

B. Document Review

1. The facility's "Policy #HIS-VI-00" stated: "F. Entries should be consistent and continuous. The medical records must not contain blank spaces or lines where comments could be added at a later date."

2. A review of minutes of the Performance Improvement Committee from the January 20, 2015 meeting of the Performance Improvement Committee pages 8-9 of 11 reviewed adherence to documentation guidelines as per the facility's policies and stated, "Areas of concern include...and Physician Progress notes/all sections completed at 72 hours (only 56% compliant)."

C. Staff Interview

In an interview with the Medical Director on 8/18/2015, he acknowledged these deficiencies: "We have lost our Medical Records person. These should have been completed."

Based upon record review, document review, and interview, the Medical director failed to:

I. Ensure that complete and legible psychiatric assessments were documented for eight (8) of 10 sample patients (A1, B1, B2, C1, C2, D1, D2 and F1). Assessments were either handwritten on a template which lacked specificity and individualization or dictated in a manner which omitted key features of a complete and thorough psychiatric evaluation. These deficiencies create incomplete assessments potentially resulting in inadequate treatment and protracted hospital stays. (Refer to B110)

II. Ensure that psychiatric progress notes adequately and relevantly measured individualized progress toward stated goals in the patient's treatment plan for six (6) of 10 sample patients (B1, B2, C1, C2, C3 and D2). Entries often reflected brief observations and failed to indicate how well the patient is responding to treatment and progressing toward set goals. Additionally, multiple signed notes contained blank spaces where transcription was not complete. These deficiencies lead to care which is not appropriately recorded potentially protracting hospital stays and/or causing the potential for medical error. (Refer to B126)

III. Ensure comprehensive Master Treatment Plans (MTPs), were individualized, behavioral, and specific with all necessary components for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). Specifically, the MTPs did not include the following: 1) observable, patient focused, measurable, and behaviorally stated goals (Refer to B121) and 2) individualized treatment interventions (Refer to B122). Failure to develop individualized MTPs with all the necessary components hampers the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's treatment needs not being met.

Based on record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action to ensure that individualized treatment plans were develop to clearly delineated active treatment oriented nursing interventions to address specific patient problems and assist patients to accomplishment treatment goals for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). Specifically, Master Treatment Plans (MTPs):

(1) Included routine and generic nursing functions such as "assessing," "monitoring," "checking in," "encouraging" and "administering medications" written as active treatment interventions for eight (8) of 10 active sample patients (A1, A2, B1, B2, C2, C3, D1 and F1);

(2) Failed to include a specific frequency of contact to ensure intensive active treatment interventions. Instead, several nursing interventions were listed to be implemented on an "as needed" or "PRN" basis instead of including a specific and scheduled frequency of contact to ensure the intensive required for active treatment for six (6) of 10 active sample patients (A1, A2, B1, B2, C2 and C3); and

(3) Failed to include a medication group on the treatment plan that was listed on the group schedules and attended by eight (8) of 10 active sample patients (B1, B2, C1, C2, C3, D1, D2 and F1).

These deficiencies potentially result in nursing staff being unable to provide consistent and focus active treatment.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (8/3/15), A2 (8/4/15), B1 (8/14/15), B2 (7/31/15), C1 (8/17/15), C2 (8/4/15), C3 (8/3/15), D1 (7/23/15, D2 (8/12/15) and F1 (8/11/15). This review revealed the following deficiencies related to psychiatric problems on MTPs.

I. Failure to Include Individualized Interventions

A. Record Review

A review of medical records revealed the "Interdisciplinary Master Treatment Plans" contained the following routine and generic nursing functions written as interventions instead of individualized specific interventions to assist patients to accomplish treatment goals. Several statements, written as interventions, were identical or similarly worded despite different presenting symptoms and/or needs for each patient.

1. Patient A1's MTP contained the following routine and generic nursing functions for Problem #1 "Depression with Suicidal Ideations..."

RN Intervention - "Conduct suicidal reassessments." "Administer medications as ordered & encourage compliance [with] medication."

2. Patient A2's MTP contained the following routine and generic and routine nursing function for Problem #1 "Depression/Danger to self."

RN Intervention - "Assess for SI [suicidal ideation] & monitor." "Assess medication responses and adjust medication as needed."

3. Patient B1's MTP contained the following routine and generic nursing function for Problem #1 "Psychotic Behaviors."

RN Intervention - "Daily check-ins & use of coping skills."

4. Patient B2's MTP contained the following routine and generic nursing function for Problem #2: "Noncompliance of Medication or Treatment..."

RN Intervention - "Assess the patient's ability to recognize the need for treatment and the patient's understanding of his/her illness."

5. Patient C2's MTP contained the following routine and generic and routine function for Problem #1: "Depression with Suicidal Ideation."

RN Intervention - "Assess [Patient's name] for S/I [suicidal ideation]."

6. Patient C3's MTP dated 8/3/15 contained the following routine and generic nursing function for Problem #1 "Danger to self..."

RN Intervention - "Assess pt [patient] for SI [suicidal ideation]."

7. Patient D1's MTP contained the following routine and generic nursing function for Problem #1: "Psychotic Behaviors."

RN Intervention: "Assess medication response, side effects, and make adjustment as indicated."

8. Patient F1's MTP contained the following routine and generic nursing functions for the following problems.

Problem #1: "Suicidal Threats..."

RN Intervention - "Encourage use of safety crisis plan content to assist [with] success [with] after care tx [treatment]."

Problem #2: "...reports abusing alcohol..."

RN Intervention - "[MD's name] will assess medication responses and adjust medication as needed." [Note: Although it was not within the scope of practice for RNs to adjust medications, two (2) RN's names were handwritten for this intervention on the MTP.] This identical or similarly worded intervention was also included on the MTPs of three (3) other active sample patients above (A2, D1 and D2).

B. Staff Interview

During interview on 8/18/10 at 3:15 p.m., the Director of Nursing acknowledged that statements were written as routine and generic nursing functions rather than interventions to assist patients to meet their specific needs and accomplish treatment goals. She agreed that the RN's scope of practice did not allow adjustment of medications.

II. Failure to Include Scheduled Frequency of Contact for Interventions.

1. Patient A1

Problem a: "Depression with Suicidal Ideation."

RN Intervention - "Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment. "The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

2. Patient A2

Problem a: "Depression/Danger to Self."

RN Interventions - "Educate [Patient's name] on the benefits of taking all prescribed medications as prescribed by psychiatrist their side effects, and the importance of medication compliance. The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

"Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment." The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

3. Patient B1

Problem: "Psychotic Behavior...."

RN Intervention - "Educate patient on the benefits of taking medication, and the important of medication compliance." "Explore with [Patient's name] any concerns from the changes in medication." The only frequency listed was "When medication changes are made." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for active treatment interventions assigned on the MTP.

4. Patient B2

a. Problem: "Psychotic Behaviors..."

RN Intervention - "Educate [Patient's name] on the benefits of taking medication and the important of medication compliance." The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

b. Problem: "ETOH [Alcohol]," "Opiates"

RN Intervention - "Explore the patient's understanding of their current need for hospitalization as it relates to the patient's alcohol/substance abuse." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

5. Patient C2

Problem: "Alteration in Thought Process."

RN Intervention - "Explore with [Patient's name] any concerns or benefits from the changes in medication." The frequency was "PRN." This type of frequency of contact listed for the above interventions failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

6. Patient C3

Problem: "Danger to self."

RN Intervention - "Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment. There was no apparent frequency listed for this intervention.

B. Staff Interview

During interview on 8/18/15 at 3:15 p.m., the Director of Nursing acknowledged that some intervention statements on the treatment plan did not include a regularly scheduled frequency of contact.

III. Failure to Include Groups Attended by Patients on the Master Treatment Plan

A. Document Review

1. A review of the facility's unit group schedule revealed that a RN led Medication Education Group was to be conduct on each Saturday on the Adult Psychiatric Units (B, C1, C2, D, and E/F). This group was not included on the MPTs for Patients B1, B2, C1, C2, C3, D1, D2, and F1.

2. A review of the "Group Notes" Form for each patient listed above revealed that these patients had attended at least one group and the medical record showed documentation of patient's non-attendance and in one case alternative one-to-one treatment provided.

B. Staff Interview

During interview on 8/18/15 at 3:15 p.m., the Director of Nursing admitted that the medication education Group assigned to RNs was not included on MTPs. She stated, "It should have been included. We are doing something that we are not getting credit for."

Based on record review and interview, it was determined that the Director of Social Work failed to monitor and take corrective action to ensure that individualized treatment plans were develop to clearly delineated active treatment oriented social work interventions to address specific patient problems and assist patients to accomplishment treatment goals for 10 of 10 active sample patients (A1, A2, B1, B2, C1, C2, C3, D1, D2 and F1). Specifically, Master Treatment Plans (MTPs):

(1) Included routine and generic social work functions such as "assessing," " monitoring," "checking in," "encouraging" and "administering medications" written as active treatment interventions for seven (7) of 10 active sample patients (A1, B1, B2, C1, C2, C3 and D1).

(2) Failed to include a specific frequency of contact to ensure intensive active treatment interventions. Instead, several social work interventions were listed to be implemented on a "PRN" basis instead of including a specific and scheduled frequency of contact to ensure the intensive required for active treatment for five (5) of 10 active sample patients (B1, B2, C2, C3 and D1).

These deficiencies potentially result in social work staff being unable to provide consistent and focus active treatment.

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (8/3/15), A2 (8/4/15), B1 (8/14/15), B2 (7/31/15), C1 (8/17/15), C2 (8/4/15), C3 (8/3/15), D1 (7/23/15, D2 (8/12/15) and F1 (8/11/15). This review revealed the following deficiencies related to psychiatric problems on MTPs.

I. Failure to Include Individualized Interventions

A. Record Review

A review of medical records revealed the "Interdisciplinary Master Treatment Plans" contained the following routine and generic social work functions written as active treatment interventions instead of individualized specific interventions to assist patients to accomplish treatment goals. Several statements, written as interventions, were identical or similarly worded despite different presenting symptoms and/or needs for each patient.

1. Patient A1's MTP contained the following routine and generic social work function for Problem #1 "Depression with Suicidal Ideations..."

SW Intervention - "Check-ins with [Patient's name] regarding mood, negative and suicidal thoughts, as well as significant behavioral changes in condition."

2. Patient B1's MTP contained the following routine and generic social work functions for Problem #1 "Psychotic Behaviors."

SW Intervention - "Will encourage [him/her] to sign a release of information to allow staff to explore preceding events to admission, baseline level of functioning, discharge planning and treatment process." "Will schedule an aftercare appointment a referral for a CMH to allow [Patient's name] to continue services on an outpatient basis."

3. Patient B2's MTP contained the following routine and generic discipline functions for Problem #1: "Psychotic Behaviors."

SW Intervention - "Obtain information from family member/support person such as [Patient's name] baseline, relevant history and behavior prior to admission."

4. Patient C1's MTP contained the following routine and generic social work functions for Problem #1: "Alteration in Thought Process."

SW Intervention - "Check in with patient regarding presence of hallucinations. Provide Support as needed." "Contact [Patient's name] to obtain additional information..."

5. Patient C2's MTP contained the following routine and generic social work functions for Problem #1: "Depression with Suicidal Ideation."

SW Interventions - "Provide check-in with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition." "Contact pt's [patient's] guardian, casemanger, and AFC staff to obtain additional information and discuss the tx [treatment] and discharge plan."

6. Patient C3's MTP dated 8/3/15 contained the following routine and generic social work functions for Problem #1 "Danger to self..."

SW Intervention - "Assess pt [patient] for SI [suicidal ideation]." "Provide check-ins with patient regarding mood, negative and suicidal thoughts and significant behavioral changes in condition."

7. Patient D1's MTP contained the following routine and generic social work functions for Problem #2 - "Aggressive Behaviors..."

SW Interventions - "Staff will encourage patient to utilize positive coping skills and healthy alternatives to aggressive behaviors for at least two (2) consecutive days prior to discharge." "Encourage patient to discuss any questions or concerns with [his/her] psychiatrist and/or charge nurse."

B. Staff Interview

During interview on 8/19/15 at 10:00 a.m., the MTPs were reviews. The Director of Social work initially did not agreed that some social work intervention statements were routine social work functions and stated, "These are very important." She later acknowledged that the interventions failed to be specifically related to each patient's presenting problems. She agreed that the intervention regarding "release of information" should be stated to reflect the patient's behavior that resulted in his/her refusal to sign a "release of information."

II. Failure to Include Scheduled Frequency of Contact for Interventions.

1. Patient B1

Problem: "Psychotic Behavior...."

SW Intervention - "Educate patient on the benefits of taking medication, and the important of medication compliance." "Explore with [Patient's name] any concerns from the changes in medication." The only frequency listed was "When medication changes are made." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for active treatment interventions assigned on the MTP.

2. Patient B2

a. Problem: "Psychotic Behaviors..."

SW Intervention - "Educate [Patient's name] on the benefits of taking medication and the important of medication compliance." The frequency was "Upon admin [administration of new med [medication] and as needed." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

3. Patient C2

Problem a: "Depression with Suicidal Ideation."

SW Intervention - "Educate patient regarding symptoms of depression and importance of compliance with treatment." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

Problem b: "Alteration in Thought Process."

SW Intervention - "Educate patient on the benefits of taking medication and the importance of medication compliance." The frequency for this intervention was "Process Group."

SW Intervention - "Explore with [Patient's name] any concerns or benefits from the changes in medication." The frequency was "PRN."

The interventions above failed to provide the specific and regularly scheduled implementation time necessary for intensive active treatment.

4. Patient C3

Problem: "Danger to self."

SW Intervention - "Educate [Patient's name] regarding symptoms of depression and importance of compliance with treatment. There was no frequency listed for this intervention.

5. Patient D1

Problem: "Psychotic Behavior...."

SW Intervention - "Staff will encourage patient to utilize positive coping skills and healthy alternatives to aggressive behaviors for at least two (2) consecutive days prior to discharge." The frequency was "PRN." This type of frequency of contact failed to provide the specific and regularly scheduled implementation time necessary for active treatment interventions assigned on the MTP.

B. Staff Interview

During interview on 8/19/15 at 10:00 a.m., the MTPs were reviewed with the Director of Social work. She acknowledged the frequency of contact was listed as PRN and agreed that some social work interventions were not scheduled to be conducted on a regularly scheduled basis.