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Based on record reviews and interviews the Governing Body failed to ensure the contract agreements for Respiratory, Laboratory, Radiology, and Dietary Services were provided under acceptable standards of practice as evidenced by a lack of documented evaluations conducted by the Quality Assurance/Performance Improvement (QAPI) Program Committee that included identification of quality and performance problems and implemented corrective actions to ensure the monitoring and trending of the corrective/improvement activities and documented those evaluations. Findings:

Review of the hospital's QAPI Program data/indicators, dated July 2013 through July 2014 revealed there failed to be indicators developed and implemented for the contracted services of Respiratory Therapy, Laboratory, Radiology and Dietary Services. Continued review of the QAPI data revealed the contracted services mentioned above were not being tracked or trended for quality of service and/or effectiveness of the services they provided.

Review of the Governing Body meeting minutes, dated 01/15/2014, revealed a lack of documented evidence the above listed contracted services were or had been evaluated to ensure they were provided by acceptable standards of practice.

Interviews, 07/09/14 at 9:00am, with S1 Administrator, S2 Director of Nursing (DON), S9 Corporate Chief Operating Officer confirmed indicators had not been formulated and implemented for the contracted services of Respiratory Therapy, Radiology, Laboratory, and Dietary.

Further interview, 07/09/14 at 1:15pm with S1 Administrator, confirmed that the last evaluation/s of the above mentioned contracted services were conducted in May 2013.

Based on record reviews and interviews the Governing Body failed to ensure the contract agreements for Respiratory, Laboratory, Radiology and Dietary Services were provided in a safe and effective manner as evidenced by a lack of documented evaluations by the hospital's Quality Assurance/Performance Improvement (QAPI) Program Committee that included identification of quality and performance problems and implement corrective activities and to ensure the monitoring and trending of the corrective/improvement activities and documented evidence that the QAPI Committee reported the evaluations to the Governing Body. Findings:

Review of the hospital's QAPI Program data/indicators, dated July 2013 through July 2014 revealed there failed to be indicators developed and implemented for the contracted services of Respiratory Therapy, Laboratory, Radiology and Dietary Services. Continued review of the QAPI data revealed the contracted services mentioned above were not being tracked or trended for safety and/or effectiveness of the services.

Review of the Governing Body meeting minutes, dated 01/15/2014, revealed a lack of documented evidence the above listed contracted services were or had been evaluated.

Interviews, 07/09/14 at 9:00am, with S1 Administrator, S2 Director of Nursing (DON), S9 Corporate Chief Operating Officer confirmed indicators had not been formulated and implemented for the contracted services of Respiratory Therapy, Radiology, Laboratory, and Dietary.

Further interview, 07/09/14 at 1:15pm with S1 Administrator, confirmed that the last evaluation/s of the above mentioned contracted services were conducted in May 2013.

Based upon review of contract service agreements and staff interviews, the hospital failed to ensure the scope and nature of the services provided were delineated as evidenced by failing to ensure the contract agreements for Radiological, Laboratory, and Respiratory Care Services were specific for the scope and nature of the service to be provided. Findings:

Review of Hospital A's contract agreement with the hospital revealed the body of the contract failed to identify the provision of the contract services which were to be provided to the patients by Hospital A's Radiology, Laboratory, and Respiratory Care Departments.

The hospital failed to ensure the contract agreement for Radiology, Laboratory and Respiratory Services were specific as to the time frame/s required for test results (i.e. STAT laboratory results sent to the hospital with in 1 hour, etc; STAT chest x-ray completed and interpreted within 1 hour), and described the contractor responsibilities and the hospital's required time frames for obtaining and reporting of the test results for Radiology, Laboratory, and Respiratory Care Services.

On 07/09/14 at 9:00am, interviews with S1 Administrator, S2 Director of Nursing (DON), S8 Corporate Chief Nursing Officer and S9 Corporate Chief Operating Officer confirmed Respiratory, Radiology, and Laboratory services were provided by contract agreement with Hospital A. S1 Administrator further confirmed the contract agreement did not specify time frames for reporting/obtaining radiological and/or laboratory results; nor did the contract agreement specify the type of Respiratory Therapy Services the patients were to receive.

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for geriatric psychiatric patients for ligature risks and safety risks.

Findings:
A hospital tour was conducted on 7/7/14 at 11:45 a.m. with S10RN. There were 8 double occupancy patient rooms with at least 1 (one) patient assigned to each room. All rooms were located down a single hallway in view of the nurse's station. All rooms had a bathroom within the room with a toilet and a sink. All rooms had an outside window view and all rooms opened to the main hallway. The census on 7/7/14 was 10 patients.

The following ligature risk and safety risk observations were made in all the patient rooms.
1) non break away curtains on the windows,
2) non break away curtain rods,
3) beds with upper and lower metal side rails,
4) interior bathroom doors with a 12 inch open-extended door hinge on the top of the doors,
5) interior bathroom doors with open-ended door hinges (x3 on each door)
6) exposed plumbing/pipes behind the toilets with flanged flushing handles on the toilets,
7) flanged faucet handles on the bathroom sinks with exposed plumbing/pipes behind the
sinks,
8) interior bathroom door handles on both sides of the doors were lever door handles,
9) electrical outlets in patient rooms were not of the safety type nor protected by a 5-milliampere ground-fault interrupter.
In an interview on 7/7/14 at 2:15 p.m. with S1Administrator and S2DON they were made aware of the ligature risks and the safety risks in the patient rooms. S1Administrator and S2DON indicated that the hospital was addressing some of these concerns with future renovations. S1Administrator and S2DON further indicated that patient rooms would be locked when patients were in activities and that all patients would remain on 15 minute checks. S1Administrator and S2DON indicated that the hospital had a policy on Bedrail Use in their Risk for Falls guidelines for geriatric psychiatric patients that identified bedrail risks, but the policy did not, at present, identify how the bedrail use would be monitored for patient safety. S1Administrator and S2DON indicated that there were no patients at present on suicide risks and no patients were presently on 1:1 monitoring. S1Administrator and S2DON further indicated that the admission criteria was 50 years and older.

Based on review of the hospital's Quality Assurance/Performance Improvement (QAPI) Plan/Program and interviews, the Governing Body failed to ensure all hospital services/departments were included in the QAPI Plan/Program. Findings:

Review of the hospital's QAPI Plan/Program revealed there failed to be documented evidence that Radiology, Laboratory, Respiratory Therapy and Dietary services were included and evaluated through/by the QAPI Program/Committee.

Interview, 07/09/14 at 9:20am, with S2 Director of Nursing (DON) revealed she was the Director of QAPI. Continued interview with S2 DON confirmed the above services were not included in the hospital's QAPI Program. S2 DON was asked if there were indicators developed and implemented for Radiology, Laboratory, Respiratory Therapy and Dietary services, she replied "no". S2 DON agreed all services provided by the hospital should be reflected in the QAPI Program.

Interviews, 07/09/14 at 10:00am, with S1 Administrator, S2 DON, S8 Corporate Chief Nursing Officer and S9 Corporate Chief Operating Officer revealed they all agreed that every service provided by the hospital should be reflected in the hospital's QAPI Program.

Based on reviews of 5 of 9 credentialing files, Medical Staff Bylaws and interviews, the Medical Staff failed to ensure the Medical Staff Bylaws were followed as evidenced by the failure to make certain all healthcare providers (S5 Psychiatrist, S6 Physician, S7 Physician, S19 Psychiatric Nurse Practitioner, S20 Psychiatrist) who applied for privileges had the two required letters of references. Findings:

Review of the credentialing files for S5 Psychiatrist, S6 Physician, S7 Physician, S19 Psychiatric Nurse Practitioner and S20 Psychiatrist, revealed all 5 lacked documentation that the required 2 letters of reference was obtained prior to them being granted privileges to treat patients in the hospital. Continued review of their credentialing files revealed they were granted the requested privileges applied for and were listed as active and current medical staff without meeting all requirements under the Medical Staff Bylaws.

Review of the Medical Staff Bylaws revealed the following: page 7 "ARTICLE V: PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT Section 1. Application for Appointment 1. All applications for appointment to the Medical Staff shall be in writing, shall be signed by the applicant, and shall be submitted on a form prescribed by the Governing Board...The application shall require detailed information concerning the applicant's education, training, and professional experience and qualification; shall include the names of at least three persons who are knowledgeable about the applicant's professional competence and ethical character..." and page 11 "ARTICLE VI: CLINICAL PRIVILEGES Section 1. Clinical Privileges 1. Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the Governing Board...2. Every initial application for staff appointment must contain a delineation of the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant's documented education, training, experience, demonstrated competence, a minimum of 2 references...applicant shall have the burden of establishing his/her qualifications and competence..."

Interview, 07/10/14 at 8:45am, with S3 Medical Record revealed she was also responsible for the credentialing process at the hospital. S3 Medical Record stated she maintained the credentialing files for all members of the Medical Staff. S3 Medical Record confirmed the 5 above listed Medical Staff members did not have the required documented reference letters in their files.

Based on observation and interview, the hospital failed to ensure discharged patients' medical records from 2005-2012 were protected from water damage in the event the sprinkler system was activated.
Findings:
An observation on 7/7/14 at 12:00 p.m. revealed a room used for medical record storage contained 77 cardboard boxes stacked on the floor. Further observation revealed the boxes contained discharged patients' medical records and the room contained a sprinkler in the ceiling.
An observation on 7/7/14 at 12:15 p.m. revealed a closet used for medical record storage contained 51 cardboard boxes stacked on the floor and shelves. Further observation revealed the boxes contained discharged patients' medical records and the closet contained a sprinkler in the ceiling.
In an interview on 7/7/14 at 12:20 p.m. with S3MedicalRecords, she verified the room containing the 77 cardboard boxes of medical records dating from 2008-2012 had a sprinkler system in the ceiling. S3MedicalRecords also said the boxes were not waterproof in the event the sprinklers were activated. S3MedicalRecords also verified the closet contained a sprinkler system and had closed medical records dated from 2005-2007 in cardboard boxes. S3MedicalRecords said none of the medical records at the hospital had been scanned into a computer or otherwise saved. S3MedicalRecords also verified the records were not protected from water damage in the event the sprinkler system was activated.

Based on interview and record review, the facility failed to ensure all entries in the medical records were legible as evidenced by 10 (#1- #10) of 10 (#1-#10) patients having Physician's Admit Note/Psychiatric Evaluations with partially illegible handwritten entries.
Findings:
Review of the medical record for Patient #1- #10 revealed the Physician's Admit Note/Psychiatric Evaluation was partially illegible due to the handwriting of S5Psychiatrist.
During an interview on 7/9/14 at 10:25 a.m. with S10RN, she attempted to read the Physician's Admit Note/Psychiatric Evaluation for Patient #10 dated 12/23/13. S10RN was unable to read the complete section titled Reason for Admission due to the handwriting of S5Psychiatrist.
In an interview on 7/8/14 at 2:00 p.m. with S4LCSW, she said she had difficulty reading S5Psychiatrist's handwriting.
In an interview on 7/9/14 at 8:40 a.m. with S1Administrator, he verified S5Psychiatrist had handwriting that was illegible and they had addressed the issue with him in the past.
In an interview on 7/9/14 at 11:50 a.m. with S5Psychiatrist, he verified his handwriting was sometimes difficult to read.

Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist was appointed to supervise the radiology services at the hospital.
Findings:
Review of the credentialing files for the three radiologists listed as being on staff revealed none of them had been appointed as the medical director of the radiology services at the hospital.

In an interview on 7/8/14 at 12:30 p.m. with S1Administrator, he verified there had not been a radiologist appointed to be the medical director of radiological services at the hospital.

Based on review of contract agreements for Laboratory Services and interviews, the hospital failed to ensure an accurate and current written description of laboratory services provided by contract agreement/s were available to the medical staff. Findings:

Review of the contract agreement for Laboratory Services provided by Hospital A revealed there failed to be documentation relative to the laboratory studies they were to provide and if these services would or could be performed on a STAT (immediately, now) or routine basis.

Review of the contract agreement for Laboratory Services to be provided by Hospital B revealed a lack of documentation relative to the laboratory services/studies they were to provide and if the services/studies would or could be performed on a STAT or routine basis.

Interview, on 07/09/14 at 9:40am, with S1 Administrator confirmed the contract agreements, with Hospital A and Hospital B for Laboratory Services, were not accurate and current in regard to the written description of the laboratory services to be provided.

Interview, on 07/09/14 at 3:20pm with S15 Licensed Practical Nurse (LPN) revealed when asked if there was an available lab (laboratory) manual or information relative to laboratory studies/testing and which laboratory would perform and send the results for the specific lab test/study ordered, she replied, "no".

Based on interview and record reviews the hospital failed to ensure that the designated Infection Control officer was qualified through education, training, experience, or certification. This failed practice was evidenced by no documented evidence in the Infection Control officer's employee file that the Infection Control officer was qualified through ongoing education, training, experience, or certification to oversee the hospital's Infection Control Program.

Findings:
A review of the Infection Control Program manual, provided by S1Administrator and S2DON as the most current and approved by the Governing Body, revealed that the designated Infection Control officer was the Director of Nursing (S2DON).

A review of S2DON's employee personnel file revealed no documented evidence of any infection control education, training, experience, or certification.

In an interview on 7/9/14 at 1:00 p.m. with S2DON, she was asked about her infection control experience and training. S2DON indicated that she participated in infection control activities in a prior position at another facility and was oriented to this hospital's Infection Control Program by the hospital's prior DON. S2DON further indicated that she did not have any documented evidence in her employee personnel file that demonstrated any ongoing education, training, experience, or certification that qualified her to oversee the hospital's Infection Control Program. S2DON was unable to provide any documentation during the survey.

Based on interview and record reviews the hospital's Infection Control program failed to ensure that the Infection Control program had developed and implemented a system to address issues identified through its infection control data collection. This failed practice was evidenced by no documentation in the Infection Control program of an analysis of the infection control data collected, with tracking and trending, corrective interventions, monitoring and evaluations in the Infection Control program.

Findings:
A review of the Infection Control Manual, provided by S2DON as the most current and approved by the Governing Body, revealed a policy titled, "Infection Prevention and Control Program". The policy revealed in part: the Infection Control Committee through the Infection Control nurse was responsible for developing and implementing a system for identifying, reporting, investigating, preventing and controlling the spread of infections within the hospital. A further review of the Infection Control Manual revealed no documented evidence that the Infection Control Committee was analyzing the infection control data, with tracking and trending, corrective interventions, monitoring and evaluations in the Infection Control program.

In an interview on 7/9/14 at 1:30 p.m. with S2DON she indicated that she was the designated Infection Control nurse for the hospital. S2DON was asked for the documentation by the Infection Control Committee of the analysis of the data collected for the Infection Control program that included tracking and trending, interventions based on the tracking and trending and the evaluations of the interventions by the Infection Control Program. S2DON indicated that the Infection Control Committee was mostly just collecting data at this time and did not have a system in place that included an analysis of the data with tracking, trending, inventions and evaluations.

Based on record review and staff interview, the hospital provides Respiratory Care Services and failed to meet the Condition of Participation for Respiratory Care Services as evidenced by:

1) The hospital failed to ensure there was an appointed Medical Director of Respiratory Care Services. (See findings in tag A-1153)

2) The hospital failed to ensure the Medical Staff identified the type of respiratory care services provided, the qualifications required and the amount of supervision required for the personnel to perform the specified respiratory care service. (See findings in A-1161)

Based on interview and record review, the hospital failed to ensure there was an appointed Medical Director of Respiratory Care Services.
Findings:
Review of the physicians' credentialing files at the hospital revealed no physician had been appointed as Medical Director of Respiratory Services by the hospital.

In an interview on 7/8/14 at 9:30 a.m. with S1Administrator, he verified the hospital had not appointed a Medical Director of Respiratory Services.

Based on record reviews and interviews the hospital failed to ensure the Medical Staff identified the type of respiratory care services provided, the qualifications required and the amount of supervision required for the personnel to perform the specified respiratory care service. Findings:

Abbreviations used: RN-Registered Nurse; LPN-Licensed Practical Nurse; MHT-Mental Health Technician; RT-Respiratory Therapist; DON-Director of Nursing; Corporate CNO-Corporate Chief Nursing Officer; Corporate COO-Corporate Chief Operating Officer.

Review of the Medical Staff Bylaws revealed the following: page 48 "Section 8. Medical ...2. Inhalation therapy shall be under the direction of the Medical Director...3. duty of the Medical Director to monitor the activities of the therapist and to attest to the professionalism of personnel."

Review of personnel files for S10RN, S15LPN, S17LPN, S21MHT, and S14RT revealed there failed to be documented evidence that identified the type of respiratory service/procedures they could perform, qualifications, or the amount of supervision required for the performance of the specified respiratory procedure/s.

Review of S14RT's file revealed she was identified as the contracted Respiratory Therapist. Continued review of S14RT's file revealed there failed to be evidence of a current license, the license in the file revealed an expired license--expiration 2013; nor was there a list of respiratory procedures or services that S14RT was to supply/perform.

Interviews, 07/08/14 at 2:45pm, with S1 Administrator, S2 DON, S8 Corporate CNO, and S9 Corporate COO revealed the hospital maintained a contract agreement with Hospital A for Respiratory Services.

Review of the contract agreement with Hospital A for Respiratory Care Service revealed there failed to be documentation relative to the type of respiratory services that would be provided. S14RT's licensure was the only indication of "who" was to be provider of respiratory services.

There failed to be documented evidence the Medical Staff ensured the oversight of Respiratory Care Service in the hospital per the Medical Staff Bylaws.

Based on record reviews and interviews the hospital failed to ensure the psychiatric evaluation contained supportive evidence that spoke to the patients' intellectual, memory functioning and orientation. Findings:

Review of patient #1-5 and 7-9's psychiatric evaluations revealed S5 Psychiatrist documented or co-signed the documentation made by S19 Psychiatric Nurse Practitioner.
Continued review of patients' 1-5 and 7-9 psychiatric evaluations revealed all had different boxes check marked by the psychiatrist/psychiatric nurse practitioner.

Review of the pre-printed psychiatric evaluation form, utilized by the psychiatrists and/or psychiatric nurse practitioner, revealed on page 2 of 3, was a section identified as "SENSORIUM AND COGNITION:" with the following: Orientation (boxes placed next to) Time, Place, Person; Judgement: boxes placed next to: Intact, Impaired, Mild, Moderate, Severe; Memory: Recent (box next to intact, impaired), Remote (box next to intact, impaired), Immediate Recall (box next to intact, impaired); Concentration: box next to intact, impaired; Intelligence: boxes next to Low, Average, Above Average; Attention: boxes next to intact or impaired; Abstract thinking: boxes next to age appropriate, impaired. The boxes were utilized by the psychiatrist/psychiatric nurse practitioner to place a check mark in the area/s they identified for each patient.

Continued reviews of the entire psychiatric evaluation revealed there failed to be documentation that indicated how or what method was utilized to evaluate the patients' intelligence, memory functioning and orientation.

Interview, 07/09/14 at 11:50am, with S5 Psychiatrist confirmed the psychiatric evaluations failed to include the method/s utilized to evaluate the patients' memory, intellect and orientation.

Based on reviews of 8 of 8 Psychiatric Evaluations (patient #s 1-5, 7-9) and interviews, the hospital failed to ensure each patient's assets listed in the psychiatric evaluation were based on the patients' strength/s and were utilized to formulate meaningful treatment plan/s. Findings:

Review of patient #1's Psychiatric Evaluation, dated 06/27/14, revealed S5 Psychiatrist documented the following on page 2 of 3 (top of page 2), under the section titled "PATIENT ASSETS", S5 Psychiatrist placed a check mark in a box next to the word "Motivated".

Review of patient #2's Psychiatric Evaluation, dated 06/11/14, revealed S19 Psychiatric Nurse Practitioner documented the patient's assets by placement of a circle around "Other", and wrote "NH" (indicated NH was nursing home) and circled "Peer support"on page 2 of 3, under Patient Assets.

Review of patient #3's Psychiatric Evaluation, dated 06/19/14, revealed S19 Psychiatric Nurse Practitioner documented patient #3's patient assets as "Family/Peer support".

Reviews of patient #s 4, 5, 7, 8 and 9's Psychiatric Evaluations revealed the following documented assets: #4's assets, dated 06/10/14, was identified as "motivated; #5's, dated 06/21/14, was identified as "family/peer support"; #7's, dated 07/07/14, identified as "motivated"; #8's, dated 06/20/14, identified assets as "family/peer support" and "adequate finances"; and #9's, dated 06/23/14, identified assets was "motivated".

Interview, 07/09/14 at 11:50am, with S5 Psychiatrist confirmed patient assets should have been more descriptive in nature and not interpretive. S5 Psychiatrist stated he utilized a pre-printed Psychiatric Evaluation form and had thought it had all required components for a psychiatric evaluation.

Review of the pre-printed form contained all the required components; however, the section in regard to "Patient Assets" should have been completed as evidenced by a lack of descriptive patient asset/s.

Based on record reviews and interviews the hospital failed to ensure a Psychologist was available to provide necessary psychological testing.. Findings:

Reviews of a list of contract agreements, personnel files and credentialing records revealed there failed to be documentation relative to a Psychologist and/or psychological services.

Interview, 07/07/14 at 3:30pm, with S1 Administrator confirmed the hospital did not have a contract agreement for psychological testing/services nor did the hospital have a Psychologist employed.

Interview, 07/09/14 at 11:50am, with S5 Psychiatrist/Medical Director confirmed the hospital did not have psychological testing abilities.

During a follow-up interview, on 07/09/14 at 1:45pm with S1 Administrator, he agreed the hospital needed to obtain a contract agreement with a Psychologist to provide psychological tesitng services.

Based on observations, record reviews and interviews the hospital failed to ensure there was a consistent, available therapeutic activity program that supplied the patients with individualized therapeutic activities that met the needs and interests of patients and that was directed toward restoring and/or maintaining the patients optimal levels of physical and psychosocial functioning. Findings:

Abbreviations used: RN-Registered Nurse; MHT-Mental Health Technician; CTRS-Certified Therapeutic Recreation Specialist; LCSW-Licensed Clinical Social Worker; AT/CM-Activity Therapist/Case Manager.

Observations conducted, 07/07/14 at 2:00pm-3:30pm, revealed 9 patients (#s 1-9) in the "Quiet Area" (room utilized for patient/family meetings, consultation with patient/family, and for a quiet space for a patient to calm down or help to de-escalate should the patient require such an intervention). The nursing staff (unidentified RN, S15LPN, 2 unidentified MHTs) were conducting verbal activities with patient #s 1-9.

Observations conducted, (9:00am-9:15am; 10:20am-10:45am; on both days of 07/08/14 and 07/09/14), revealed S10RN conducted the first morning group session and the topic of discussion was "emotional eating". S4LCSW was observed conducting the second (10:20am-10:45am) morning group session and discussed depression and had the patients (#s 1-9) verbalize methods they had utilized to help themselves when they get depressed.

Review of 9 of 9 medical records, patient #s 1-9, revealed Multidisciplinary Treatment Plans with goals and interventions for the patients' specific diagnoses; however, there failed to be documentation that any therapeutic activities had been planned. Continued review of the medical records (patient #s 1-9) revealed S16CTRS failed to ensure the assessments conducted by S18AT/CM were accurate and were individualized for each patient.

Interview, 07/08/14 at 10:50am, with S4LCSW confirmed she conducted group sessions Monday through Friday, usually 10:15am-10:45am depending on the patients' abilities to maintain focus on the group. When questioned who conducted the therapeutic activities, S4LCSW stated that S16CTRS usually comes on Monday mornings around 10:00am to conduct the activity therapy group sessions and S18AT/CM conducted other activities through out the week. Further questioning with S4LCSW confirmed sometimes S18AT/CM was unavailable secondary to conducting discharges at another facility.

Interviews, 07/10/14 at 9:45am with unidentified MHTs (2) confirmed that they play bingo, and other board games with the patients. Further questioning of the MHTs revealed when asked what type of outside activities the patients received, both MHTs stated they took the patients outside and while the patients were sitting they would toss a "balloon" back and forth and/or kick a ball back and forth. When questioned if they (MHTs) observed the activities conducted by S16CTRS, both stated "yes". Continued questioning of the MHTs revealed S16CTRS conducted group sessions on Monday mornings and would "talk with the patients and do activities". S16CTRS was unavailable for interview.

Review of the patients' multidisciplinary treatment plans revealed there failed to be documentation relative to therapeutic activity goals and interventions for 9 of 9 patients (#s1-9) reviewed.