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Based on record review, observation and interview, the facility failed to provide active treatment, including purposeful and appropriate alternative interventions, for 3 of 3 active sample patients (A8, A14, and A24) on the Acute Adult Unit who were either not cognitively capable of participating in treatment at times and/or were not motivated to attend all groups they were assigned to. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on the unit activity schedule. Failure to provide active and appropriate treatment for these patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement. (Refer to B125.)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individualized recommendations for social work services from the data gathered for 5 of 8 active sample patients (A14, A24, B7, C7, and C13). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

1. Patient A14 was admitted on 7/29/13. The psychosocial assessment, done on 7/30/13, did not include individualized social service recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "pt. (patient) will need confirmed DC (discharge) placement and f/u (follow up) services with IHS (Indian Health Services)."

2. Patient A24 was admitted on 6/26/13. The psychosocial assessment, done on 6/27/13, did not include individualized recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "pt. (patient) will continue to f/u w (with) CODAC (acronym of an agency) and need more secure housing placement."

3. Patient B7 was admitted on 7/31/13. The psychosocial assessment, done on 8/1/13, did not include individualized recommendations. The documented recommendations were generalized statements and not based on identified psychosocial problems. They were: "name of patient] would benefit from a CDIOP (Chemical Dependency Intensive Outpatient Program) and primary care follow up apt.[sic] (appointment)."

4. Patient C7 was admitted on 7/24/13. The psychosocial assessment, done on 7/26/13, did not include individualized recommendations. The documented recommendation was generalized statement and not based on identified psychosocial problems. It was: "Safe D/C (discharge) plan in place" and were identical to social service recommendations of patient C13.

5. Patient C13 was admitted on 7/24/13. The psychosocial assessment, done on 7/24/13, did not include individualized recommendations. The documented recommendation was generalized statement and not based on identified psychosocial problems. It was: "Safe D/C plan in place" and were identical to social service recommendations of patient C7.

B. Staff Interview

During an interview on 8/6/13 at 3:25 p.m., the Director of Social Work stated, "Absolutely, I agree with you these recommendations are generic and they could be improved and individualized."

Based on record review and staff interview, it was determined that the facility failed to document an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 8 active sample patients (A8, B12 and D2). This failure potentially results in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromises future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

Patient A8 was admitted on 7/39/13. The psychiatric evaluation, done on 7/31/13 stated, "Memory Functioning - within normal limits per interview." There was no supportive information documented. The documented information was generic in nature and was identical to the same information documented for sample patients B12 (psychiatric evaluation done 7/31/13), and D2 (psychiatric evaluation done 7/31/13).

B. Staff Interviews

1. During an interview on 8/6/13 at 8:45 a.m., The Medical Director stated, "I know my docs (Doctors) are asking different questions to check memory and orientation but I understand where you are coming from. I agree it is not reflected in their documentation. I agree it looks generic."

2. During an interview on 8/6/13 at 11:15 a.m., with the CEO (Chief Executive Officer) and the Director of Quality Improvement, the Director of Quality Improvement stated, "I agree with your findings (referring to memory findings). We still have some improvement to provide."

Based on record review and interview, the facility failed to ensure that the Treatment Plan interventions for 7 of 8 active sample patients (A8, A14, A24, B12, C7, C13, and D2) consistently addressed specific treatment needs. The interventions on the Master Treatment Plans (MTPs) were primarily stated as generic discipline functions. In addition, the Plan of 1 of 8 active sample patients (B7) had no interventions listed to address 2 of three Axis I diagnoses; the Plan of 1 of 8 active sample patients (B12) listed as an intervention a statement which was a staff goal (something the staff wanted the patient to do) and not an intervention 1the staff was going to do to help the patient meet his/her goals. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients.

Findings include:

A. Record Review

1. Facility policy, # PC-001, titled "Treatment Planning", last revised 9/5/12, stated: "The treatment plan should contain specific interventions that relate to goals, are written in behavioral and measureable terms....Interventions for each appropriate discipline will be included for each problem." A new Facility policy with same policy number and name, updated 8/1/13 to reflect revised treatment plan forms, stated: "Interventions for each appropriate discipline will be included for each problem. The intervention includes the following components: Action/measure: Specific intervention [group, administration of antidepressant, activities [sic] therapy , psych testing, 1:1, suicide precautions ,etc.]."

2. Record Review revealed that many of the treatment interventions, especially for physician and nursing staff, were generic in that they focused on the routine functions of each discipline. All interventions on all plans failed to identify which intervention related to which goal. The goals on the Master Treatment Plans (MTPs) were numbered and listed in a column above the interventions, which were also numbered, but there was no correlation between the numbers, making it guesswork to tell which goal went with which intervention.

2. Patient A8
The Master Treatment Plan (MTP), dated 8/1/13, listed the following generic and routine discipline functions for the problem "Disturbed Thought Process":
"Physician/ LIP (Licensed Independent Practitioner) to assess mood, mental status, and presence of SI (suicidal ideation) 4x (times) weekly and prn (as needed)."
"Nursing to assess mood, behavioral status, orientation, and intervention on unit" q (every) shift and prn."

3. Patient A14
The MTP, dated 7/30/13, listed the following generic and routine discipline functions for the problem "Disturbed Thought Process":
"Physician/LIP to assess presence of internal stimuli 4 x's weekly and prn."
"Nursing to assess presence of internal stimuli q shift and prn."

4. Patient A24
The MTP, dated 6/27/13, listed the following generic and routine discipline functions for the problem "Disturbed Thought Process":
"Physician / LIP to assess presence of internal stimuli 4 x's weekly and prn."
"Nursing to assess presence of internal stimuli q shift and prn."

5. Patient B7
The MTP, dated 8/1/13, listed the following generic and routine discipline functions for the problem "Potential for alteration in comfort/Safety: Physiological Symptoms ETOH DETOX"
"Practitioner will order/evaluate detox management for detox protocol on admit and prn." This was a generic physician intervention.
"Staff will provide medication education in groups and 1:1(one to one)." This was a RN generic intervention.
"Staff will provide ETOH addiction education in groups and/or 1:1." This was a generic intervention.
"SS (Social Services) will assist with making appt. w OP (appointment with outpatient) follow-up." This is a generic Social Services intervention.
"Staff will provide sobriety/coping skills, education daily via group/ind (individual) or written handouts." This was a generic intervention.

The two problems not addressed in the MTP were "Depressive Disorder" and "Attention Deficit Hyperactive Disorder."

6. Patient B12
The MTP, dated 8/5/13, listed the following generic and routine discipline functions for the problem "suicidal ideation, homicidal ideation":
"[Social work] - Directed [sic] journaling related to [his/her] loss of spirituality daily." "[Name of patient] will verbalize in group [his/her] SI (suicidal Ideation) triggers daily." This is a goal not an intervention.

7. Patient C7
The MTP, dated 7/29/13, listed the following generic and routine discipline functions for the problem "mood disorder":
"Physician/LIP to assess mood, mental status, and presence of suicidal thoughts 4x's weekly and prn."
"Nursing to assess presence of suicidal thoughts, mood and affect q shift and prn."

8. Patient C13
The Master Treatment plan, dated 7/29/13, listed the following generic and routine discipline functions for the problem "mood liability:"
"Physician/nursing - will dispense and administer medication as prescribed, assess for therapeutic effect and side effects daily."
"Staff (MHT-Mental Health Technician) will encourage pt. (patient) participation in active treatment on milieu, daily groups, and CFT/FT (child family team/family therapy) meetings as scheduled daily."
"[Social work] staff will facilitate CFT/FT and assist in coordination of care for safe disposition plan 2 xs (two times)."

9. Patient D2
The MTP, dated 8/2/13, listed the following generic and routine discipline functions for the problem "aggressive behavior:"
"Physician/LIP to assess mood, mental status, presence of HI (homicidal ideation), and effectiveness of current medications regime 4x's weekly."
"Nursing to assess insight, level of participation interaction on unit q shift and prn."
"[Activity therapist] - activities [sic] assessment x1(times one)." This is a staff function not an intervention.
"Provide structured activities to increase impulse control by: helping pt. (patient) participate in groups to (illegible) peer-leisure skills, social skills." The discipline of the person was "BHT (Behavior Health Technician)." This is a generic staff function.

B. Interviews

1. During an interview on 8/6/13 at 11:15 p.m, the Director of Quality Improvement stated, "I agree with your (treatment plan) findings. We still have some improvement to provide [sic]."

2. In an interview on 8/7/13 at 8:30 a.m., the generic nature of the interventions on the Master Treatment plans was discussed with the Nursing Director. She did not agree. The Nursing Director felt that the problem was solved by making sure all the blanks were filled in on the original pre-printed treatment plan forms, since on the forms, which were primarily a check list, there was some opportunity to add a word here and there for such things as a specific medication name or the name of a specific group assigned to the patient.

Based on record review and interviews, the facility failed to identify the name and/or discipline responsible for each specific intervention on the Master Treatment Plan (MTP) for 3 of 8 active sample patients (B7, B12, and D2). These practices results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out.

Findings include:

A. Record Review

1. Facility policy, #PC-001, titled "Treatment Planning", dated 9/5/12, stated: "The Treatment Plan should contain specific interventions....and...include person responsible for implementation." The revised Treatment Plan policy, dated 8/1/13, stated that the interventions should include: "Responsible Staff:-The name[s] and credentials/discipline of the specific staff members responsible for the provision of the intervention."

2. Patient B7
The Master Treatment plan, dated 8/1/13, listed the following staff interventions associated with the problem "potential for alteration in comfort/ safety- Physiological symptoms ETOH detox (alcohol detox). N+V (nausea and vomiting), triggers, dizziness":

"Practitioner will order/evaluate detox management for detox protocol." No name was listed as the responsible staff. The "discipline" column on the form said "psychiatrist".
"Staff will provide medication education in groups and 1-1 (one to one)." No name was cited for responsible staff. The discipline was "RN."
"SS (social services) will assist with making appt. w OP (appointment with outpatient) follow-up." No name was listed.
"Staff will provide sobriety/coping skills, education daily via group/ind (individual) or written handouts." No name listed as responsible staff(s). The discipline listed was "all staff."

3. Patient B12
The MTP, dated 8/5/13, listed the following staff intervention associated with "suicidal ideation/homicidal ideation as evidenced by verbalized thoughts/depression" as follows:

"Directed [sic] journaling related to [his/her] loss of spirituality." "[Name of patient] will verbalize in group SI (suicidal ideation) triggers." The same first initial and last name of the responsible person was listed for each intervention, but there was no discipline included.
There was no physician's signature or intervention on the treatment plan, so the physician's name was not included.

4. Patient D2
The MTP, dated8/2/13, listed the following staff intervention associated with the problem "Aggressive Behavior":

"Provide structured activities to increase impulse control by: helping pt. (patient) participate in groups to a (illegible) peer-leisure skills, social skills." The discipline of the person was "BHT (Behavior Health Technician)." No specific name was mentioned.

B. Interview

In an interview on 8/6/13 at 8:45 a.m., the problem of lack of names and disciplines documented on the treatment plans as the responsible person to be held accountable for making sure an individual intervention was being carried out was discussed with the Medical Director. He was shown the MTP, dated 8/1/13, of active sample patient B7. The Medical Director stated, "I don't see names of the disciplines on this treatment plan."

Based on record review, observation and interview, the facility failed to provide active treatment, including purposeful and appropriate alternative interventions, for 3 of 3 active sample patients (A8, A14, and A24) on the Acute Adult Unit who were either not cognitively capable of participating in treatment at times or/and were not motivated to attend all groups they were assigned to. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on the unit activity schedule. Failure to provide active and appropriate treatment for these patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvements.

Findings include:

A. Patient A8

1. Patient A8 was admitted on 7/30/13. According to the Psychiatric Evaluation, dated 7/31/13, A8 "had been extremely anxious, having suicidal thoughts and thoughts of taking a whole bottle of Xanax.....[S/he] acknowledges substance abuse stating [s/he] smokes weed to increase [his/her] appetite and that is the only thing that helps[his/her] anxious [sic]........[S/he] has a voice inside [his/her] head that [s/he] argues with named Marcus....."

2. Patient A8 was just getting out of the shower on 8/5/13 at 11:00 a.m. when [s/he] was told by staff that a surveyor would like to talk to him/her. The patient came into the Dayroom still slightly damp but was shivering violently. When asked if s/he was cold, patient A8 stated, "No. I'm just nervous. Marcus is talking to me." The patient was unable to follow the conversation or answer questions clearly because "Marcus" was telling him/her what to say. During the interview, patient A8 was asked if s/he had attended any groups that day. S/he stated, "I did, but left after 5 minutes because I was nervous."

3. In an interview on 8/5/13 at 9:40 a.m., RN #1 was asked for an activity schedule for patient A8. She provided a unit schedule and stated all patients were expected to attend the groups listed on the schedule. (Groups listed on the schedule were listed as Therapy groups; the same groups listed in "Group Progress Notes" were listed as "Process group").

4. On A8's Master Treatment plan (MTP) dated 8/1/13, identified problems were "self harm" and "disturbed thought process." The listed groups for both problems were "Psych Education and Art Therapy." The "Psych Education" group listed in the MTP was not on the unit schedule. However, A8 was observed briefly attending a "Therapy" group, which was on the unit schedule daily at 2:00 p.m., being held in the Dayroom on 8/5/13. The group started at 2:10 p.m. A8 walked into the group at 2:18 p.m., turned around and walked out of the group without sitting down. The group leader did not say anything to the patient about where s/he was going or why.

5. A review of the Acute Adult unit's activity schedule revealed other groups that were not on A8's Master Treatment plan. They were "social skills" group, held Sunday through Friday at 10 a.m. "Dietary" groups on Wednesdays at 12:30 p.m. and "medication" group on Saturday at 12:30 p.m. The schedule had a total of 11 therapeutic groups on the schedule for the 5 day period reviewed - Thursday 8/1/13 through Monday 8/5/13.

6. A review of A8's "Group Progress Notes" from 8/1/13 to 8/5/13 showed that s/he was documented on for 8 groups during that 5 day period. They were as follows:

8/1/13 - "Process group: mindfulness - 2:00 p.m. - 3:00p.m. - "Patient actively participated."

8/1/13 - "Art therapy " group - 3:30 p.m. - 4:30 p.m. - "Patient attended." However, the "Observation rounds sheet" showed the patient in the Dayroom during this period.

8/2/13 - "Process group: assertiveness training" - 2:00 p.m. - 3:00 p.m. -Pt. "Actively participated." However "Observation rounds sheet" showed patient in hallway during this period.

8/2/13 - "Art therapy" group ("Art Therapy" could be offered as a specific focus group by an Art therapist or offered under a "Process Group" as a theme or topic chosen by the group leader conducting the latter group who did not have to be an Art therapist.) - 3:30 p.m. - 4:30 p.m. - "Patient did not attend....Alternative offered: journaling, working on a packet, reading, resting. (Note- all alternative offerings for all assigned patients were in the form of a work sheet given to them to work on themselves. The alternatives were not a one to one staff/patient interaction) .The patient refused." "Observation rounds sheet" showed patient in own room during this period.

8/3/13 - "Process group: card of thanks" - 3:30 p.m. - 4:30 p.m. - "minimal participation ...Pt. (patient) left early." "Observation rounds sheet" showed patient in own room and Dayroom during this period.

8/4/13 - "Process group: personal responsibility" - 2:00 p.m. - 3:00 p.m. - "Minimal participation...Pt was asked to explain admit [sic]....Pt slept remainder of group."

8/4/13 - "Process group: motivation" - 3:30 p.m. - 4:30 p.m. - "Pt. refused. Alternative offered- Healthy body/healthy mind."

8/5/13 - "Process group: Still Life" - 3:30 p.m. - 4:30 p.m. - "Alternative offered - Coping skills work sheet....Pt. refused." "Observation rounds sheet" showed patient in room at 3:30 p.m. And outside after that.

Summary - A8 was listed as attending 6 of 8 groups. However the "Observation Rounds Sheet" had the patient in [his/her] room during the times of five of the 8 groups.

7. There were no updates on A8's Master Treatment plan to address the patient's inability and/or unwillingness to participate in many of the therapy groups. Many of the alternative activities documented as offered in the progress notes, such as self-directed reading and journaling, were inappropriate for A8 and did not meet his/her needs due to the patient's severe anxiety and inability to concentrate.

8. In an interview on 8/6/13 at 11:15 a.m., the failure to address A8's problem of poor group attendance and the subsequent offering of activities that might meet his/her wants and needs, such as 1:1 interaction, was discussed with MD #1. She stated, "I understand what you are saying."

B. Patient A14

1. Patient A14 was admitted on 7/29/13. According to the Psychiatric Evaluation, dated 7/30/13, A14 is "a poor historian....Two weeks ago [s/he] was hospitalized at [name of hospital]. [S/he] was diagnosed as having schizophrenia. The patient was discharged home on medication with some degree of improvement. The patient however was not taking [his/her] medication....The patient was petitioned by [his/her] father....When read the allegations on the patient; the patient was unable to track [sic]. The patient was very concrete and maintained tense affect. However, [s/he] was unable to engage in intelligible coherent dialogue."

2. Patient A14 was first observed sitting in a chair in the Dayroom on Rincon unit on 8/5/13 around 7:50 a.m. S/he sat quietly and was not observed talking or looking at anyone in particular. The patient did not show any outward signs that s/he knew someone was talking to him/her. After several attempts of the interviewer to engage A14, A14 just smiled. S/he subsequently would say "yes" or "no" inappropriately to questions asked.

3. On A14's MTP, dated 7/30/13, an identified problem was "disturbed thought processes as manifested by: confusion, psychosis and hallucinations." The listed groups under interventions were " Psych Education groups - Therapy groups to address coping skills" and "Provide non-threatening supervised opportunity to encourage peer interaction in group sessions including: social skills groups." A14 did not attend the "Therapy" group held on 8/5/13 at 2:10 p.m. The patient was observed in his/her room in bed with eyes closed at 2:30 p.m.

4. A review of the Rincon unit activity scheduled for the period of 8/1/13 to 8/5/13 (Thursday through Monday) documented the same total number of groups (11) offered as inpatient A8's listing above. The one group from A14's MTP "Psycho Education" was not listed as such on the unit schedule.

5. A review of A14's "Group progress notes" for the period of 8/1/13 to 8/5/13 showed that s/he was documented on for 8 groups during that same period. They were as follows:

8/1/13 - "Process Group: mindfulness" - from 2:00 p.m. to 3:00 p.m. - "Patient did not attend group....Alternative offered - 'Who am I? (a hand out work sheet)'....Patient refused alternative too." "Observation rounds sheet" listed patient as in room during this period.

8/1/13- "Art therapy" - from 3:30 p.m. to 4:30 p.m. "Pt. attended group x 60 min (minutes) ...Participation minimal. Confused affect. Labile. Cognitive preoccupied [sic]. Other - internal stim (stimuli) AEB (as evidenced by) laughing out loud."

8/2/13 - "Process group: assertiveness training" - from 2:00 p.m. to 3:00 p.m. - "Patient did not attend group Reason: wound care [Patient had scraped the left side of his/her face during a physical hold].... Alternative offered - 'Journal.'....Accepted alternative - No." "Observation rounds sheet" documented patient in own room during this period.

8/2/13 - "Process group: Art therapy" - from 3:30 p.m. to 4:30 p.m. - "Pt attended group x (times) 35 min (minutes) prior to leaving. Did not participate, cried spontaneously, then brightened on contact [sic]. Psychotic but pleasant."

8/3/13 - "Process group: card of thanks" - from 3:30 p.m. to 4:30 p.m. - "Active participation. Calm, inappropriate. Did not address group's topic."

8/4/13 - "Process group: Personal Responsibility" - from 2:00 p.m. to 3:00 p.m. - "Participation level - none. Flat, preoccupied. Pt was observed talking and laughing to [him/herself] through group. Pt's eyes were moving rapidly when pt was not speaking. Pt asked to 'pass' when asked to accept personal responsibility for hospitalization."

8/4/13 - "Process group: Motivation" - from 3:30 p.m. to 4:30 p.m. - "Pt refused to attend. Alternatives offered: 'Healthy Body/Healthy Mind'....Patient refused alternative." "Observation Rounds Sheet" had patient in room during this period.

8/5/13 - "Process group: Still Life" - from 3:30 p.m. to 4:30 p.m. - "Pt. refused to attend group....Alternatives offered: 'Coping Skills' worksheet." The "Observation Rounds Sheet" documented patient as being in Dayroom during this period.

Summary - A14 attended 4 of 8 groups offered in the five day period selected. However, in 1 of 4 groups attended, the patient had zero participation. Many of the alternative activities offered in the progress notes, such as Journal, problem solving, were inappropriate for A14 and did not meet his/her needs due to the patient's severe confusion and inability to concentrate.

7. There were no updates on A14's Master Treatment plan to address the patient's inability and/or unwillingness to participate in meeting of the therapy groups. Many of the alternative activities offered in the progress notes, such as reading and journaling were inappropriate for A14 due to the patient's severe cognitive problems.

8. In an interview on 8/5/13 at 11:00 a.m., the failure of patient A14 to consistently attend groups offered on the unit was discussed with MD #2. He stated that A14 was so psychotic that s/he was not at a point where s/he could even get any benefit out of groups. "The patient is responding to external [sic] stimuli." When it was mentioned that the current MTP did not meet this patient's needs, MD #2 agreed. He stated that he was focusing on stabilizing the patient on medication.

C. Patient A24

1. Patient A24 was admitted on 6/26/13. According to the Psychiatric Evaluation, dated 5/23/13, A24 "presents on a revoked court treatment [sic]....The patient is an extremely poor historian, answering only 'yes' or 'no' to questions and is unable to participate in conversation on any topic unless it is a topic [s/he] is specifically interested in...[S/he] will only give one or two word answers to questions but is able to engage in longer conversations, including full sentences, if it is something [s/he] is interested in."

2. On 8/5/13 at 10:00 a.m., an attempt was made to interview A24 who was in his/her room at the time. A24 did come out of the room, but when approached for an interview, the patient refused to talk and immediately got up from the chair and returned to his/her room.

3. Patient A24 did not attend the "Therapy" group scheduled on the unit at 2:00 p.m. on 8/5/13. S/he was in his/her room on the bed.

4. On A24's MTP, dated 6/27/13, an identified problem was "disturbed thought process as manifested by: confusion, psychosis and hallucinations." The two groups listed for this problem were: "Therapy" group to address coping skills and "Social Skills" group. A review of the Rincon unit activity schedule for the period of 8/1/13 to 8/5/13 (Thursday through Monday) showed that 11 therapeutic groups were scheduled for the period of 8/1/13 to 8/5/13.

5. A review of A24's "Group progress notes" for the period of 8/1/13 to 8/5/13 showed that s/he was documented on for 8 groups during this period. The patient did not attend any of the groups. The documentation was as follows:

8/1/13 - "Process group: mindfulness" from 2:00 p.m. to 3:00 p.m. "Alternative offered- 'Who am I?' (a work sheet)." There was no documentation on whether the patient attended. The rest of the note was blank.

8/2/13 - "Process group: Assertiveness Training" - from 2:00 p.m. to 3:00 p.m. - "Patient did not attend group.... Alternative offered - 'journal.'...Alternative not accepted."

8/2/13 - "Process group: Art Therapy (the focus in this process group)" - from 3:30 p.m. to 4:30 p.m. - "Patient did not attend group ....Alternative offered- journaling, reading, rest in own room on unit.... Pt attended group x (times) 0 min (minutes)."


8/3/13 - "Brainstorming" - from 2:00 p.m. to 3:00 p.m. - "Patient did not attend group. Pt refused. 'I don't like f---ing groups.'... Participation - None".

8/3/13 - "Process group: Card of Thanks" - from 3:30 p.m. to 4:30 p.m. - "Pt refused. Alternative offered: 'Problem Solving'....Pt did not accept the alternative."

8/4/13 - "Process group: Personal Responsibility." "Patient did not attend group. Reason: Not appropriate." "Alternative offered: healthy thinking (a work sheet)." The patient did not accept the alternative.

8/4/13 - "Process group: Motivation (a work sheet)." "Patient did not attend group. Pt refused." Patient also refused alternative offered which was: "Healthy body/healthy mind (a work sheet)."

8/5/13 - "Process group: Still Life" - "Patient did not attend. Alternative offered: Coping skills work sheets." There was no indication of patient's acceptance or refusal of alternative. Area was left blank.

The "Observation rounds sheet" for the period of 8/1/13 to 8/4/13 had the patient in room during all the group times listed above. There was no rounds sheet for the group held on 8/5/13.

6. There were no updates on A24's Master Treatment plan to address the patient's inability and/or unwillingness to participate in meeting of the therapy groups. Many of the alternative activities offered in the progress notes, such as reading and journaling were inappropriate for A24 due to the patient's severe withdrawal and lack of interest.

7. In an interview on 8/6/13 at 11:15 a.m., the failure to address A24's problem of poor group attendance and the subsequent offer of activities that might interest and/or meet the patient's needs was discussed with MD #1. She stated that A24 was being considered for admission to the State Hospital. "The patient stays in [his/her] room twenty three hours per day. [Name of patient] might be suitable for ECT (electric shock therapy), but we don't do that treatment at this facility."

Based on record review and staff interview, it was determined that the facility failed to ensure that the discharge summaries for 5 of 5 sampled discharged patients (E1, E2, E3, E4, and E5) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk were not available to the aftercare providers.

Findings include:

A. Record Review

1. Patient E1 was discharged on 6/28/13. In the Discharge summary dictated on 6/28/13, the condition on discharge was documented only as "improved from admission."

2. Patient E2 was discharged on 7/2/13. In the Discharge summary dictated on 7/3/13, the condition on discharge was documented only as "improved."

3. Patient E3 was discharged on 6/27/13. In the Discharge summary dictated on 6/27/13, the condition on discharge was documented only as "improved."

4. Patient E4 was discharged on 6/29/13. In the Discharge summary dictated on 7/1/13, the condition on discharge was documented only as "stable."

5. Patient E5 was discharged on 6/24/13. In the Discharge summary dictated on 6/24/13, the condition on discharge was documented only as "patient is ready for discharge."

B. Staff Interview:

During an interview on 8/6/13 at 08:45 AM, Medical Director stated, "We are improving but it (improvement) is not 100% yet. It is a work in progress."

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically the Medical Director failed to assure that:

I. Physicians documented an estimate of memory functioning with supportive information in the psychiatric evaluation for 3 of 8 active sample patients (A8, B12 and D2). This failure potentially results in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromises future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116.)

II. The Treatment Plan interventions for 7 of 8 active sample patients (A8, A14, A24, B12, C7, C13, and D2) consistently addressed specific treatment needs. The interventions on the Master Treatment plans were primarily stated as generic discipline functions. In addition, 1 of 8 active sample patients (B7) had no intervention to address 2 of three Axis I diagnoses. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients. (Refer to B122.)

III. The name and discipline responsible for each specific intervention was identified on the Master Treatment Plan for 3 of 8 active sample patients (B7, B12, and D2). One and/ or the other of the requirements were missing in the plans. These practices result in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out. (Refer to B123.)

IV. Active treatment, including purposeful and appropriate alternative interventions, was provided for 3 of 3 active sample patients (A8, A14, and A24) on the Acute Adult Unit who were either not cognitively capable of participating in treatment at times or were not motivated to attend all groups they were assigned to. Rather than providing individualized treatment for these patients, the staff expected them to attend all groups listed on the unit activity schedule. Failure to provide active and appropriate treatment for these patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvements. (Refer to B125.)

V. The discharge summaries for 5 of 5 sampled discharged patients (E1, E2, E3, E4, and E5) contained a summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk were not available to the aftercare providers. (Refer to B135.)

Staff Interview:

During an interview on 8/6/13 at 8:45 AM, Medical Director stated, "We are improving but it (improvement) is not 100% yet. It is a work in progress."

Based on record review and interviews, the Nursing Director failed to:

I. Ensure that the Treatment Plan interventions for 6 of 8 active sample patients (A8, A14, A24, C7, C13, and D2) consistently addressed specific treatment needs. The Nursing interventions on the Master Treatment plans were primarily stated as generic discipline functions. In addition, 1 of 8 active sample patients (B7) had no intervention to address 2 of three Axis I diagnoses. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problems and may result in prolonged hospitalization for patients.

Findings include:

1. Patient A8
The Master Treatment plan (MTP), dated 8/1/13, listed the following Nursing generic and routine discipline function for the problem "disturbed thought processes:" "Nursing to assess mood, behavioral status, orientation, and intervention on unit q (every) shift and prn. (as needed)"

2. Patient A14
The MTP, dated 7/30/13, listed the following Nursing generic and routine discipline function for the problem "anxiety and related d/o (disorder)":
"Nursing to assess thought process, mood, affect and sleep pattern q shift and prn."

3. Patient A24
The MTP, dated 6/27/13, listed the following Nursing generic and routine discipline function for the problem "disturbed thought process":
"Nursing to assess presence of internal stimuli q shift and prn."

4. Patient C7
The MTP, dated 7/29/13, listed the following Nursing generic and routine discipline functions for the problem "mood disorder":
"Nursing to assess presence of suicidal thoughts, mood and affect q shift a prn."

5. Patient C13
The Master Treatment plan, dated 7/29/13, listed the following Nursing generic and routine discipline function for the problem "mood liability":
"Nursing - will dispense and administer medication as prescribed, assess for therapeutic effect and side effects daily."

6. Patient D2
The MTP, dated 8/2/13, listed the following Nursing generic and routine discipline function for the problem "aggressive behavior":
"Nursing to assess insight, level of participation interaction on unit q shift and prn."

In an interview on 8/7/13 at 8:30 a.m., the generic nursing interventions were discussed with the Interim Nursing Director. She disagreed with the findings. She felt that the problem had been solved by making sure that all the blanks on the preprinted treatment plan forms were filled out. The Nursing Director felt that the problem was solved by making sure all the blanks were filled in on the original pre-printed treatment plan forms, since on the forms, which were primarily a check list, there was some opportunity to add a word here and there for such things as a specific medication name or the name of a specific group assigned to the patient.

II. Identify the name and discipline responsible for each specific Nursing intervention on the Master Treatment Plan for 2 of 8 active sample patients (B7 and D2). One and/or the other of the requirements were missing in the plans. These practices results in the facility's inability to clearly monitor staff responsibility for seeing specific interventions are carried out.

Findings Include:

Record Review

1. Facility policy, #PC-001, titled "Treatment Planning", dated 9/5/12, stated: "The Treatment Plan should contain specific interventions....and... include person responsible for implementation." The revised Treatment Plan policy, dated 8/1/13, stated that the interventions should include: "Responsible Staff:-The name[s] and credentials/discipline of the specific staff members responsible for the provision of the intervention."

2. Patient B7
The Master Treatment plan, dated 8/1/13, listed the following Nursing staff intervention associated with the problem "potential for alteration in comfort/ safety- Physiological symptoms ETOH detox (alcohol detox)....":
"Staff will provide medication education in groups and 1-1 (one to one)." No name was cited for responsible staff. The discipline was "RN."

3. Patient D2
The MTP, dated 8/2/13, listed the following staff intervention associated with the problem "Aggressive Behavior":
"Provide structured activities to increase impulse control by: helping pt. (patient) participate in groups to (illegible) peer-leisure skills, social skills." The discipline of the person was "BHT (Behavior Health Technician)." No specific name was mentioned.

Based on record review and interviews, it was determined that the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided to patients at the facility. Specifically the Director of Social Services failed to assure that Social service assessments included individualized recommendations for social work services from the data gathered for 5 of 8 active sample patients (A8, A14, A24, B7, C7, and C13). As a result, social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108 for record findings.)

B.Staff Interview:

During an interview on 8/6/13 at 3:25 p.m., the Director of Social Work stated, "Absolutely, I agree with you these recommendations are generic and they could be improved and individualized."

Based on record review and interview, the facility failed to provide a MSW- prepared Director of Social Work, or to assign one of MSW- level staff currently employed at the facility to fulfill the duties, functions and responsibilities of the Director of Social Work. As a result, there was no professionally designed and directed social work program for 8 of 8 sample patients (A8, A14, A24, B7, B12, C7, C13, and D2 ), as well as the facility's entire patient population.

Record Review:

1. The review of resume of the Director of Social Work indicated that the Director of Social Work was not MSW qualified.

2. The job description of A & R Evaluator (Assessment and Referral), who is a MSW and a Licensed Clinical Social Worker, provided by the Director of Human Resources on 8/5/13, did not specifically include the responsibilities to also provide clinical supervision to all inpatient social workers because the Director of Social Services did not hold a Master's degree in social work.

Staff Interviews:

1. During an interview on 8/5/13 at 10:25 a.m., SW1 stated, "I report to the Director of Social Services. She is responsible for my day to day work as a social worker. I see the A & R director weekly for my clinical supervision hours because I am working on my licensure and I need supervisory hours."

2. During an interview on 8/5/13 at 11:55 a.m., the Director of Social Services stated, "I do not have a MSW. My degree is a PhD in clinical psychology. I supervise all social workers for their day to day social work functions and responsibilities. We do have a MSW staff (referring to A & R Evaluator) in our intake area that provides weekly clinical supervision to unlicensed social workers and counselors."

3. During an interview on 8/5/13 at 12:55 p.m., the Director of Human Resources stated, "She (referring to A & R Evaluator) provides clinical supervision to therapists and social workers who are not licensed."

4. During an interview on 8/6/13 at 10:30 a.m., A & R Evaluator stated, "I work full time in our intake department. I provide weekly clinical supervision only to unlicensed counselor and social workers. Some of the social workers also need clinical supervisory hours for their licensure exam. The Director of Social Work is responsible for the day to day supervision of all inpatient social workers." When asked whether she also provided clinical supervision to licensed inpatient social workers A & R Evaluator stated, "Technically no, they (referring to licensed counselors and licensed social workers) do not need my supervision and I do not supervise them. The Director of Social Services provides day to day supervision to all inpatient social work."

5. During an interview on 8/6/13 at 8:45 AM on the qualifications of the Director of Social Services, the Medical Director stated, "I see she has a PhD in Psychology. Maybe it works from the management and clinical oversight perspective but it does not meet the Medicare standard."