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Based on record review and interview, the facility failed to list patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 4 of 4 active sample patients (A, B, C, and D). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths.

Findings include:

A. Record Review

The following Psychiatric Evaluations failed to include any description of assets within the body of the reports (dates of evaluations are in parentheses).

Patient A (10/31/12); Patient B (11/3/12); Patient C (11/7/12); and Patient D (11/7/12)

B. Interview

During an interview on 11/8/12 at 9:45 AM, the Medical Director, who was also the attending physician for all four patients, was shown the examples of the Psychiatric Evaluations. The Medical Director agreed with the findings and stated "we need to include that in the record."

I. Based on record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 5 of 5 discharged patients whose records were reviewed (D1, D2, D3, D4 and D5). This failure to provide information that identifies either effective or ineffective treatment strategies for the individual patient compromises the effective transfer of the patient's care to the next care provider.

Findings include:

A. Record Review:

1. Patient D1: In a Discharge Summary dated 11/1/12, the section titled "Summary of Hospital Course" noted medical treatment for depression, opiate detoxification and pain issues. There was no information relating to other forms of treatment provided during the hospital stay, for example response to individual, group or family therapies; response to activity therapy or milieu.

2. Patient D2: In a Discharge Summary dated 11/1/12, the section titled "Summary of Hospital Course" noted medical treatment for bipolar disorder and opiate detoxification issues. There was no information relating to other forms of treatment provided during the hospital stay, for example response to individual, group or family therapies; response to activity therapy or milieu.

3. Patient D3: In a Discharge Summary dated 11/1/12, the section titled "Summary of Hospital Course" noted medical treatment for opiate dependency issues. There was no information relating to other forms of treatment provided during the hospital stay, for example response to individual, group or family therapies; response to activity therapy or milieu.

4. Patient D4: In a Discharge Summary dated 11/1/12, the section titled "Summary of Hospital Course" noted medical treatment for depression and pain issues. There was no information relating to other forms of treatment provided during the hospital stay, for example response to individual, group or family therapies; response to activity therapy or milieu.

5. Patient D5: In a Discharge Summary dated 11/7/12, the section titled "Summary of Hospital Course" noted medical treatment for depression and opiate detoxification issues. There was no information relating to other forms of treatment provided during the hospital stay, for example response to individual, group or family therapies; response to activity therapy or milieu.

B. Interview

In an interview on 11/8/12 at 9:45 AM, the Medical Director was shown examples of the Discharge Summaries noted above and agreed with the findings. She stated that she had been writing discharge notes in the progress note area and learned recently that the discharge summaries needed to be more detailed.

II. Based on record review, policy review and interview, the facility failed to ensure that discharge summaries were completed within 15 days of discharge, per the facility's policy, in 5 of 5 discharge records reviewed (D1, D2, D3, D4 and D5). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with providers at the next level of care.

Findings include:

A. Record Review

1. Patient D1 was discharged on 9/25/12. The Discharge Summary was signed and completed by the attending psychiatrist on 11/1/12 (21 days late).

2. Patient D2 was discharged on 10/2/12. The Discharge Summary was signed and completed by the attending psychiatrist on 11/1/12 (14 days late).

3. Patient D3 was discharged on 10/6/12. The Discharge Summary was signed and completed by the attending psychiatrist on 11/1/12 (10 days late).

4. Patient D4 was discharged on 10/4/12. The Discharge Summary was signed and completed by the attending psychiatrist on 11/1/12 (12 days late).

5. Patient D5 was discharged on 10/18/12. The Discharge Summary was signed and completed by the attending psychiatrist on 11/7/12 (6 days late).

B. Policy Review

Facility Policy IM-01, developed 5/2012, titled "Medical Record Documentation" noted the following:

"Section C: Timely and Complete Documentation; The Discharge Summary should be recorded at the time of discharge, but no later than (15) days after discharge."

C. Interview

In an interview on 11/8/12 at 9:45 AM, the Medical Director, who was also the attending physician for all five patients, was informed of the lateness of discharge summaries and agreed that she had not been completing the discharge summaries in a timely manner.

Based on record review and interview, the Medical Director failed to:

I. Ensure that physicians listed patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 4 of 4 active sample patients (A, B, C, and D). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths. (Refer to B117)

II. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication for 5 of 5 discharged patients whose records were reviewed (D1, D2, D3, D4 and D5). This failure to co provide information that identifies either effective or ineffective treatment strategies for the individual patient compromises the effective transfer of the patient's care to the next care provider. (Refer to B133-I)

III. Ensure that physicians completed discharge summaries within 15 days of discharge per the facility's policy in 5 of 5 discharge records reviewed (D1, D2, D3, D4 and D5). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with providers at the next level of care. (Refer to B133-II)