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Based on record review and interview it was determined that the hospital was not primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons. 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6) were admitted for detox and the goals on the treatment plans of 5 of 6 sample patients (A1, A2, A3, A4 and A6) focused primarily on substance abuse. This practice resulted in patients with detox/substance abuse concerns being admitted to a psychiatric unit, with goals and treatment emphasis on substance abuse, and limits bed availability for individuals with mental health issues which could potentially result in delayed hospitalization for individuals experiencing acute mental health needs.

Findings include:

A. Record Review

1. Patient A1 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission. The Master Treatment Plan dated 8/18/13 had a goal: "Develop an understanding of a personal pattern of relapse to help sustain long-term recovery."

2. Patient A2 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission. The master treatment plan dated 8/6/13 had goals: (1) "Establish a sustained recovery, free from the use of all mood-altering substances." (2) "Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan."

3. Patient A3 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission. The master treatment plan dated 8/15/13 had goals: (1) "Acquire the necessary skills to maintain long-term sobriety from all mood-altering substances." (2) "Establish a recovery pattern from alcohol abuse that includes social supports and implementation of relapse prevention guidelines."

4. Patient A4 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission. The master treatment plan dated 8/16/13 had goals: (1) "Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan." (2) "Acquire the necessary skills to maintain long-term sobriety from all mood-altering substances."


5. Patient A5 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission.

6. Patient A6 - census sheet provided by the Program Director on 8/19/13 indicated a detox admission. The master treatment plan dated 8/12/13 had goals: (1) "Accept the fact of chemical dependence and begin to actively participate in a recovery program." (2) "Terminate anxiety-producing dreams that cause awakening."

B. Interview


During an interview on 8/20/13 at 9:40 a.m., Nurse Practitioner 1 (NP1) confirmed the findings and stated, "Groups on the Crisis Stabilization Unit (a unit not included in the inpatient survey) are more concentrated for mental health."

Based on interview and document review, the hospital failed to maintain medical records that contained accurate and complete information regarding the assessment and active treatment of 6 of 6 sample active patients (A1, A2, A3, A4, A5, and A6) and discharge summaries of 4 of 5 discharged patients (B1, B2, B3, and B5). Specifically, the hospital failed to:

I. Ensure that 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6) had treatment plans which contained a substantiated diagnosis (Refer to B120). This resulted in a lack of diagnostic information needed for the treatment team to formulate an appropriate treatment plan.

II. Ensure that 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6) had treatment plans which contain individual specific and measurable long term and short term goals. This resulted in a lack of clarity and direction to the treatment plan. (Refer to B121)

III. Develop treatment plans that identified clearly delineated physician, nursing and social work interventions to address specific treatment needs for 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6). Instead, treatment plans included a list of interventions which were routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that did not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122 and B123)

IV. Ensure that 6 of 6 sample patients had progress notes which included recommendations for treatment plan revisions, and measured patient progress toward goals. This resulted in lack of direction for the treatment planning process. (Refer to B131 and B132)

V. Ensure that 4 of 5 discharge sample patients (B1, B2, B3, and B5) had discharge summaries which recapitulated the hospitalization and provided a summary of the patient's condition at time of discharge. This resulted in a lack of continuity of care from inpatient to outpatient settings. (Refer to B133 and B135)

Based on a record review, document review, and interview, the facility failed to collaboratively develop a master treatment plan for 6 of 6 sample records reviewed (A1, A2, A3, A4, A5, A6). Instead the treatment plan was written by the social worker or the social work intern and then reviewed and signed by staff from other disciplines. Furthermore, the document entitled Master Treatment Plan in 6 or 6 sample records (A1, A2, A3, A4, A5, A6) failed to include:

1. A substantiated diagnosis (see B120);

2. Long-term and short-term goals that were stated in observable, measurable, or behavioral terms (see B121);

3. Specific treatment interventions (see B122); and

4. The name and discipline of the person responsible for treatment (see B123). These failures to collaboratively develop a master treatment plan which included required elements results in a lack of coordinated and organized treatment.

Specific findings include:

A. Record Review

1. The master treatment plan (8/18/13) for Patient A1 was signed by the social worker only on 8/18/13 at 2:23 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/19/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

2. The master treatment plan (8/6/13) for Patient A2 was signed by the social work intern only on 8/6/13 at 12:59 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/7/13, 8/9/13, and 8/12/13, and 8/18/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

3. The master treatment plan (8/15/13) for Patient A3 was signed by the social work intern only on 8/15/13 at 6:54 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/16/13, 8/18/13/ and 8/19/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

4. The master treatment plan (8/16/13) for Patient A4 was signed by the social worker only on 8/16/13 at 2:26 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/18/13 and 8/19/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

5. The master treatment plan (8/18/13) for Patient A5 was signed by the social worker only on 8/18/13 at 3:05 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/19/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

6. The master treatment plan (8/12/13) for Patient A6 was signed by the social work intern only on 8/12/13 at 7:56 p.m. when it was written. The addendum stated that the plan was reviewed by staff from other disciplines on 8/13/13, 8/16/13 and 8/18/13. Nothing was added to the treatment plan when it was reviewed by staff from other disciplines.

B. Document Review

Hospital Policy entitled "Multi-Disciplinary Treatment Plan (No. 905.11)" and signed by the Hospital Executive Director on 5/31/13 reads: "Treatment plans are formulated in a multi-disciplinary manner with each discipline contributing to the plan..."

C. Interviews

1. Registered Nurse 1 (RN1) stated in an interview on 8/20/13 at 9:15 a.m., "The nurse writes the initial (admission) treatment plan, but we have no contact with the master treatment plan. The master treatment plan is all done by the social worker. Nursing used to identify patient problems and goals and interventions on the written treatment plan, but that changed when we went to the electronic plan."

2. The Medical Records Manager stated in an interview on 8/20/13 at 2:30 p.m., "The treatment plans in the electronic record are geared toward out-patient. We are developing treatment plans that work for the in-patient."

Based on a record review, document review, and interview, the facility failed to ensure that treatment plans included substantiated diagnoses. Substantiated psychiatric diagnoses were not recorded on the Master Treatment Plans for 6 of 6 (A1, A2, A3, A4, A5, A6) active sample patients. Absence of a substantiated diagnosis or diagnoses compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Record Review

1. The master treatment plan (8/18/13) for Patient A1 did not include a substantiated diagnosis.

2. The master treatment plan (8/6/13) for Patient A2 did not include a substantiated diagnosis.

3. The master treatment plan (8/15/13) for Patient A3 did not include a substantiated diagnosis.

4. The master treatment plan (8/16/13) for Patient A4 did not include a substantiated diagnosis.

5. The master treatment plan (8/18/13) for Patient A5 did not include a substantiated diagnosis.

6. The master treatment plan (8/12/13) for Patient A6 did not include a substantiated diagnosis.

B. Document Review

Hospital Policy entitled "Multi-Disciplinary Treatment Plan (No. 905.11)" and signed by the Hospital Executive Director on 5/31/13 reads: "All five (5) Axis [sic] must be identified by MD on psych evaluation/Treatment Plan." (The first three "axes" listed on a patient's record are for the psychiatric and medical diagnoses.)

C. Interview

The Hospital Executive Director stated in an interview on 8/20/13 at 2:30 p.m., "The current treatment plan does not include the diagnosis, but it should."

Based on record review, document review, and interview, the facility failed to ensure that treatment plans included long-term and short-term goals that were stated in observable, measurable, and behavioral terms for 6 of 6 (A1, A2, A3, A4, A5, A6) active sample patients. Absence of observable, measurable, and behavioral goals hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs.

Findings include:

A. Record Review

1. The Master Treatment Plan (8/18/13) for Patient A1 identified one treatment goal, which was not observable, measurable, or behavioral: "Develop an understanding of a personal pattern of relapse to help sustain long-term recovery."

2. The master treatment plan (8/6/13) for Patient A2 identified two treatment goals, which were not observable, measurable, or behavioral: (1) "Establish a sustained recovery, free from the use of all mood-altering substances." (2) "Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan."

3. The master treatment plan (8/15/13) for Patient A3 identified two treatment goals, which were not observable, measurable, or behavioral: (1) "Acquire the necessary skills to maintain long-term sobriety from all mood-altering substances." (2) "Establish a recovery pattern from alcohol abuse that includes social supports and implementation of relapse prevention guidelines."

4. The master treatment plan (8/16/13) for Patient A4 identified two treatment goals, which were not observable, measurable, or behavioral: (1) "Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan." (2) "Acquire the necessary skills to maintain long-term sobriety from all mood-altering substances."

5. The master treatment plan (8/18/13) for Patient A5 identified one treatment goal, which was not observable, measurable, or behavioral: "Develop healthy cognitive patterns and beliefs about self and the world that lead to alleviation and help prevent the relapse of depression symptoms."

6. The master treatment plan (8/12/13) for Patient A6 identified two treatment goals, which were not observable, measurable, or behavioral: (1) "Accept the fact of chemical dependence and begin to actively participate in a recovery program." (2) Terminate anxiety-producing dreams that cause awakening."

B. Document Review

Hospital Policy entitled "Multi-Disciplinary Treatment Plan (No. 905.11) and signed by the Hospital Executive Director on 5/31/13 reads:" Specific goals with measurable objectives and anticipated time frames expected to meet these goals will be established in the Treatment Plan with goals and progress discussed."

C. The Director of the In-Patient Unit, in an interview on 8/20/13 at 3:30 p.m. stated that the goals identified in the treatment plans reviewed (A1, A2, A3, A4, A5, A6) were not measurable and that no target date for achieving the goals had been recorded.

Based on a record review, document review, and interview, the facility failed to develop treatment plans that identified specific interventions for the multi-disciplinary team to provide to address specific patient problems. Instead, interventions on the plans were limited, general, and non-specific for 6 or 6 sample patients (A1, A2, A3, A4, A5, A6). This failure to document specific treatment approaches by each member of the multi-disciplinary team results in a treatment plan that does not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. The master treatment plan (8/18/13) for Patient A1 identified only one intervention to be implemented by the treatment team: "Encourage and reinforce consistent attendance at 12-step recovery program meetings three or more times per week." No activity or provider was identified to carry out this intervention.

2. The master treatment plan (8/6/13) for Patient A2 identified two interventions to be implemented by the treatment team: (1) "Assess the client's current skill in managing common everyday stressors; use behavioral and cognitive restructuring techniques to build social and/or communication skills to manage these challenges (or assign Restoring Socialization Comfort in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma)." (2) "Teach the client a coping package involving calming strategies, thought stopping, positive self-talk, and attentional focusing skills." "Group" was the non-specific activity identified to carry out both of these interventions. No provider was identified to carry out this activity.

3. The master treatment plan (8/15/13) for Patient A3 identified two interventions to be implemented by the treatment team: (1) "Explore the client's schema and self-talk that weaken his/her resolve to remain abstinent; challenge the biases; assist him/her in generating realistic self-talk that correct for the biases and build resilience." (2) "Teach the client coping skills to reduce depression (e.g., identify and replace distorted cognitive messages that trigger feelings of depression; reinforce positive self-esteem based in accomplishments and renewed respect for the intrinsic value of self; encourage physical exercise and social contacts in activities of daily living schedule; reinforce assertive expression of emotions.)" "Group" and "Detox" were the non-specific activities identified to carry out both of these interventions. No provider was identified to carry out these activities.

4. The master treatment plan (8/16/13) for Patient A4 identified two interventions to be implemented by the treatment team: (1) "Instruct the client to routinely use strategies learned in therapy while building social interactions and relationships (or assign Relapse Triggers in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma." (2) "Teach the client a coping package involving calming strategies, thought stopping, positive self-talk, and attentional focusing skills to manage urges to use chemical substances." "Group", "individual", and "Detox" were the non-specific activities identified to carry out both of these interventions. No provider was identified to carry out these interventions.

5. The master treatment plan (8/18/13) for Patient A5 identified one intervention to be implemented by the treatment team: "Teach the client more about depression and to accept some sadness as a normal variation in feeling." No activity or provider was identified to carry out this intervention.

6. The master treatment plan 8/12/13) for Patient A6 identified two interventions to be implemented by the treatment team: (1) "Gather a complete drug/alcohol history from the client, including the amount and pattern of his/her use, signs and symptoms of use, and negative life consequences." (2) "Assist the client to keep a journal of sleep patterns, stressors, thoughts, feeling, and activities associated with going to bed, and other relevant client-specific factors possibly associated with sleep problems; process the material for details of the sleep-wake cycle." Peer support, group, and detox were the non-specific activities identified to carry out both of these interventions. No provider was identified to carry out these interventions.

B. Document Review

The Hospital Policy entitled "Multi-Disciplinary Treatment Plan (No. 905.11)" and signed by the Hospital Executive Director on 5/31/13 offers no comment or direction as to how or whether interventions should be included in the master treatment plan.

C. Interview

Nurse Practitioner 1 stated in an interview on 8/20/13 at 10:15 a.m., "Treatment plans are generalized. They are not detailed." Social Worker1 stated during the same interview, "We do a lot of things that do not get reflected in the treatment plan."

Based on record review, document review, and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the master treatment plans for 6 or 6 sample patients (A1, A2, A3, A4, A5, A6). This failure resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. The master treatment plan (8/18/13) for Patient A1 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

2. The master treatment plan (8/6/13) for Patient A2 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

3. The master treatment plan (8/15/13) for Patient A3 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

4. The master treatment plan (8/16/13) for Patient A4 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

5. The master treatment plan (8/18/13) for Patient A5 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

6. The master treatment plan (8/12/13) for Patient A6 did not include the name or discipline of the staff person responsible for implementing any part of the treatment plan.

B. Document Review

The Hospital Policy entitled "Multi-Disciplinary Treatment Plan (No. 905.11)" and signed by the Hospital Executive Director on 5/31/13 offers no comment or direction as to how or whether the staff person responsible for the intervention should be included in the master treatment plan.

C. Interview

The Director of the In-Patient Unit stated in an interview on 8/19/13 at noon, "The electronic record does not tell you who is responsible for providing the treatment. The documentation needs an adjustment to define the responsible party. The Director of Nursing signs off on the master treatment plan, but that does not mean that she is the responsible person for the intervention."

Based on record review and interview, the facility failed to document progress notes which included recommendations for treatment plan review for 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6). This failure had the potential of causing unnecessary lengthening of hospitalization.

Findings include:

A. Record Review

1. The electronic record of Patient A1 admitted 8/16/13 contained no progress notes with recommendations for treatment plan revision.

2. The electronic record of Patient A2 admitted 8/5/13 contained no progress notes with recommendation for treatment plan revision.

3. The electronic record of Patient A3 admitted 8/15/13 contained no progress notes with recommendations for treatment plan revision.

4. The electronic record of Patient A4 admitted 8/15/13 contained no progress notes with recommendations for treatment plan revision.

5. The electronic record of Patient A5 admitted 8/16/13 contained no progress notes with recommendations for treatment plan revision.

6. The electronic record of Patient A6 admitted 8/12/13 contained no progress notes with recommendations for treatment plan revision.

B. Interview

1. During an interview, 8/20/13 at 1:40 pm, the Director of Medical Records confirmed the findings.

2. During an interview, 8/20/13 at 2:30 pm, the Executive Director confirmed the findings.

Based on record review and interview, the facility failed to provide progress notes that contained assessments of progress toward goals on the treatment plan. This failure had the potential of failing to direct care toward patients' changing clinical needs and prolonging patients' hospitalizations.

Findings include:

A. Record Review

1. The electronic record of Patient A1 admitted 8/16/13 lacked notes documenting progress toward treatment plan goals.

2. The electronic record of Patient A2 admitted 8/5/13 lacked notes documenting progress toward treatment plan goals.

3. The electronic record of Patient A3 admitted 8/15/13 lacked notes documenting progress toward treatment plan goals.

4. The electronic record of Patient A4 admitted 8/15/13 lacked notes documenting progress toward treatment plan goals.

5. The electronic record of Patient A5 admitted 8/16/13 lacked notes documenting progress toward treatment plan goals.

6. The electronic record of Patient A6 admitted 8/12/13 lacked notes documenting progress toward treatment plan goals.

B. Interview

1. During an interview, 8/20/13 at 1:40 pm, the Director of Medical Records confirmed the findings.

2. During an interview, 8/20/13 at 2:30 pm, the Executive Director confirmed the findings.

Based on record review and interview, the facility failed to provide discharge summaries for 4 of 5 sample patients (B1, B2, B3, and B5), over a month after the patients' discharges. This failure has the potential in delaying continuity of appropriate care post hospitalization, since no information is available to outpatient providers who provide follow-up care.

Findings include:

A. Record Review

1. Patient B1was admitted 7/10/13 and discharged 7/16/13. The electronic record did not contain a completed discharge summary as of 8/19/13.

2. Patient B2 was admitted 7/9/13 and discharged 7/12/13. The electronic record did not contain a completed discharge summary as of 8/19/13.

3. Patient B3 was admitted 7/11/13 and discharged 7/16/13. The electronic record did not contain a completed discharge summary as of 8/19/13.

4. Patient B5 was admitted 7/8/13 and discharged 7/17/13. The electronic record did not contain a completed discharge summary as of 8/19/13.

B. Interview

During an interview, 8/20/13 at 1:40 pm, the Medical Records Director confirmed the findings.

Based on record review and interview, the facility failed to provide discharge summaries containing a summary of the patient's condition at time of discharge for 4 of 5 sample patients (B1, B2, B3, and B5). These summaries were not in the record over a month after the patients' discharges. This failure could result in patients not receiving appropriate aftercare due to insufficient information in the transition of care.

Findings include:

A. Record Review

1. Patient B1was admitted 7/10/13 and discharged 7/16/13. The electronic record did not contain a summary of patient's condition on discharge.

2. Patient B2 was admitted 7/9/13 and discharged 7/12/13. The electronic record did not contain a summary of patient's condition on discharge.

3. Patient B3 was admitted 7/11/13 and discharged 7/16/13. The electronic record did not contain a summary of patient's condition on discharge.

4. Patient B5 was admitted 7/8/13 and discharged 7/17/13. The electronic record did not contain a summary of patient's condition on discharge.

B. Interview

During an interview, 8/20/13 at 1:40 pm, the Medical Records Director confirmed the findings.

Based on record review, document review, and interview, the facility failed to utilize staff in a manner that ensured comprehensive, collaborative, and individualized treatment for 6 of 6 sample patients (A1, A2, A3, A4, A5, A6). This failure results in the patients being hospitalized without receiving maximum therapeutic interventions to direct them toward restoration of mental health.

Specifically, the facility failed to:

1. Ensure that the Medical Director monitored and evaluated the quality and appropriateness of services and treatment provided by the medical staff. Treatment plans did not include specific individualized interventions that staff would deliver and did not indicate physician roles. In addition, progress notes written by staff did not document patient response to treatment, or make recommendations for adjustments to the treatment plan, and discharge summaries were not available to those following up with the patient in the community after discharge. (See B144)

2. Ensure that the Director of Nursing demonstrated competence to direct nursing staff to provide skilled psychiatric care and to participate in interdisciplinary treatment planning. Nursing staff were not involved in the formulation of Master Treatment Plans, and were not involved in psychiatric care of the patients. (See B148)

3. Ensure that the Director of Social Work monitored and evaluated the quality and appropriateness of social services furnished; social work staff were not identified as providing any treatment modality on the Master Treatment Plans. (See B152)

4. Ensure that the therapeutic activity program was appropriate to the needs of the patients; only one staff member was available to patients, and only weekdays, during daytime hours. (See B157 and B158)

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

I. Ensure that treatment plans contained specific and individualized interventions for 6 of 6 active sample patients (A1, A2, A3, A4, A5, and A6). Interventions identified were generic staff functions without any specificity for each patient. This deficient practice could lead to prolonged hospitalization and ineffective treatment. (Refer to B122)

II. Ensure that treatment plans identified the psychiatrist responsible for providing treatment for 6 of 6 active sample patients (A1, A2, A3, A4, A5, and A6). This deficient practice fails to provide psychiatric leadership to the treatment process. (Refer to B123)

III. Ensure that the physicians and psychiatric nurse practitioners provided recommendations for treatment plan revisions and had progress notes which assessed patient progress toward goals for 6 of 6 sample patients (A1, A2, A3, A4, A5 and A6). These failures result in treatment plans not directing care based on the patient's status. (Refer to B131 and B132)

IV. Ensure that discharge summaries were completed within 30 days of discharge and contained a summary of each patient's hospital course and condition at the time of discharge for 4 of 5 discharge sample patients (B1, B2, B3, and B5). This failure could potentially affect continuity of care. (Refer B133 and B135)

Based on interviews and record reviews, the Director of Nursing (DON) failed to ensure that nursing staff participated in the interdisciplinary formulation of individual master treatment plans. Furthermore, the Director of Nursing failed to ensure that nursing staff participated in treatment with emphasis on psychiatric nursing, in addition to the medical responsibilities provided to patients undergoing detox. This failure results in a lack of psychiatric nursing intervention that can then impede patients' progress toward their treatment goals.

Findings include:

A. Interviews

1. RN1 stated in an interview on 8/20/13 at 9:15 a.m., "The nurse writes the initial treatment plan, but we have no contact with the master treatment plan. The master treatment plan is all done by the social worker. Nursing used to identify patient problems and goals and interventions on the written treatment plan, but that changed when we went to the electronic plan."

2. The Director of Nursing stated in an interview on 8/20/13 at 1:30 p.m., "The role of the nurse is to educate the patient about their medications, teach about nutrition, and smoking cessation, and to be a social worker at times and lend the patients an ear....Nursing does not lead any groups."

3. The Director of the In-Patient Unit stated in an interview on 8/19/13 at noon, "The electronic record does not tell you who is responsible for providing the treatment. The documentation needs an adjustment to define the responsible party. The Director of Nursing signs off on the master treatment plan, but that does not mean that she is the responsible person for the intervention."

B. Record Review

1. The master treatment plan (8/18/13) for Patient A1 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

2. The master treatment plan (8/6/13) for Patient A2 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

3. The master treatment plan (8/15/13) for Patient A3 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

4. The master treatment plan (8/16/13) for Patient A4 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

5. The master treatment plan (8/18/13) for Patient A5 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

6. The master treatment plan (8/12/13) for Patient A6 did not include the name or discipline of a nurse responsible for implementing any part of the treatment plan.

Based on record review and interview, the Director of Social Work failed to monitor the work of the inpatient social workers to ensure appropriate documentation and participation in the treatment planning process for 6 of 6 sample patients (A1, A2, A3, A4, A5, and A6). This failure results in a lack of direct in the social work function which can result in prolonged hospital stays.

Findings include:

A. Record Review

1. Patient A1 - the master treatment plan dated 8/18/13 did not contain an intervention with the social worker as the responsible staff person.

2. Patient A2 - the master treatment plan dated 8/6/13 did not contain an intervention with the social worker as the responsible staff person.

3. Patient A3 - the master treatment plan dated 8/15/13 did not contain an intervention with the social worker as the responsible staff person.

4. Patient A4 - the master treatment plan dated 8/16/13 did not contain an intervention with the social worker as the responsible staff person.

5. Patient A5 - the master treatment plan dated 8/18/13 did not contain an intervention with the social worker as the responsible staff person.

6. Patient A6 - the master treatment plan dated 8/12/13 did not contain an intervention with the social worker as the responsible staff person.

B. Interview

During an interview 8/20/13 at 1:10 pm, the Director of Social Work confirmed the findings and stated that he had not performed a record review since October 2011 and that it was a general quantitative review of all disciplines and not specifically to assess the work of the social worker.

Based on interview, observation, and record review, the facility failed to provide a therapeutic activity program that ensured consistent availability and provision of comprehensive and individualized activity therapy for 6 of 6 active sample patients (A1, A2, A3, A4, A5, A6). This failure results in a lack of therapeutic treatment, which can then impede patients' progress toward their treatment goals.

Findings include:

A. Interviews

1. The Director of Activities stated in an interview on 8/20/13 at 9:00 a.m. that he was the only individual in the Therapeutic Activities Program. His responsibilities included working on the In-Patient Unit and the Crisis Stabilization Unit (not part of the inpatient area). He estimated his time on the In-Patient Unit to be about 50% of his work-week. He worked the day shift Monday through Friday. There was no other person in his department who was assigned to offer therapeutic activities on weekends or on the evening-shift. He had no supervisory responsibilities of other staff persons who could offer therapeutic activities at times when he was not working. He did not attend treatment team meetings and he did not contribute to the documented treatment plan. "I haven't been writing any goals for therapeutic activities in the treatment plan. I'm not sure why I am not involved. I think it is because we are in the process of changing to the computer and there is no specific place in the treatment plan for an activities goal."

2. The Coordinator of the In-Patient Unit stated in an interview on 8/20/13 at 3:30 p.m. that he supervised the Director of Activities and was in charge of in-patient programming. He stated, "When the activity director is not available, we utilize technicians. We are not expecting them to provide therapeutic activity. I know that there is Bingo on Friday nights....If the director of activity is out on vacation or has appointments, he needs to find someone to cover for him ....The expectation is that therapeutic activities would be included in the treatment plan. Unfortunately, it is not incorporated in the electronic treatment plan. We need to correct that and have a goal for therapeutic activities in the treatment plan."


3. The Director of the In-Patient Unit stated in an interview on 8/21/13 at 9:10 a.m. that there is no hospital policy related to therapeutic activities.


B. Observation


The treatment team meeting that was scheduled and met on 8/20/13 at 9:30 a.m. was not attended by the Director of Activities. Throughout the meeting, there was no discussion or comment as to how the therapeutic activities program could or would contribute to the patients' treatment goals.

C. Record Review


1. The master treatment plan (8/18/13) for Patient A1 did not include a goal or an intervention provided by the activity therapy staff.

2. The master treatment plan (8/6/13) for Patient A2 did not include a goal or an intervention provided by the activity therapy staff.

3. The master treatment plan (8/15/13) for Patient A3 did not include a goal or an intervention provided by the activity therapy staff.

4. The master treatment plan (8/16/13) for Patient A4 did not include a goal or an intervention provided by the activity therapy staff.

5. The master treatment plan (8/18/13) for Patient A5 did not include a goal or an intervention provided by the activity therapy staff.

6. The master treatment plan (8/12/13) for Patient A6 did not include a goal or an intervention provided by the activity therapy staff.

Based on interview and document review, the facility failed to provide a therapeutic activity program that ensured an adequate number of qualified therapists to provide comprehensive therapeutic activities in 6 of 6 active sample patients (A1, A2, A3, A4, A5, A6). No staff was available to provide or oversee services evenings or weekends. In addition, the Director of the Therapeutic Activities program was not qualified by the facility's criteria to direct the program. This failure results in a lack of therapeutic treatment that can then impede patients' progress toward their treatment goals.

Findings include:

A. Interviews

1. The Director of Activities stated in an interview on 8/20/13 at 9:00 a.m. that he was the only individual in the Therapeutic Activities Program. His responsibilities included working on the In-Patient Unit and the Crisis Stabilization Unit (an outpatient program). He estimated his time on the In-Patient Unit to be about 50% of his work-week. He worked the day shift Monday through Friday. There was no other person in the therapeutic activity department who was assigned to offer therapeutic activities on weekends or on the evening-shift. He had no supervisory responsibilities of other staff persons who could offer therapeutic activities at times when he was not working. He has a masters' degree in music, but not music therapy or other therapeutic activity related discipline.

2. The Coordinator of the In-Patient Unit stated in an interview on 8/20/13 at 3:30 p.m. that he supervised the Director of Activities and was in charge of in-patient programming. He stated, "When the activity director is not available, we utilize technicians. We are not expecting them to provide therapeutic activity. I know that there is Bingo on Friday nights."

B. Document Review

The job description for the Activities Coordinator on the In-Patient Unit, in effect since 7/1/2009, states: "Job Specifications: Education: Such proficiency is acquired through completion of Baccalaureate Degree in Therapeutic Recreation. Licensure, Registration, Certification: Certified, or certification eligible, by the National Council for Therapeutic Recreation as a Therapeutic Recreation Specialist. Working toward certification."