HospitalInspections.org

Based on record reviews, patient and staff interviews and observations, the facility failed to:

I. Provide social work assessments for 10 of 12 sample patients (A2, A4, A5, A6, A7, A8, A9, A10, A11, and A12) that included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring a seamless re-entry into the community that meets the patient's needs. (Refer to B108)

II. Provide comprehensive Master Treatment Plans (MTPs) that contained all required elements for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). Failure to develop treatment plans with all necessary components hampers staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met. (Refer to B118)

III. Provide Master Treatment Plans (MTPs) that identified and utilized patient strengths for 11 of 12 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11). The MTPs incorrectly listed external resources (such as "supportive family") as patient strengths and/or failed to specify how patient strengths/assets could be used to support treatment, (e.g. for de-escalation, and for teaching long-term pts how to use their strengths). Failure to identify and incorporate patient strengths in the treatment plan diminishes the effectiveness of treatment interventions, and can hamper patient's achievement of their treatment goals. (Refer to B119)

IV. Provide Master Treatment Plans (MTPs) that included long term and short-term goals stated as measurable behaviors with specific target dates for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). Some of the listed goals for patients A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11 also were stated as staff goals for patient participation in program activities (rather than patient behavioral outcomes) or were staff interventions, incorrectly identified as patient goals. Failure to develop clear patient goals with expected dates for goal achievement hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment. This potentially results in prolonged hospitalizations. (Refer to B121)

V. Provide Master Treatment Plans (MTPs) that specified the modality, frequency, and duration of all listed interventions for 11 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A8, A9, A10, A11 and A12). The MTP for patient A9 also incorrectly listed "staff goals/interventions" as patient goals. In addition, the MTPs for patients A2, A3, A7, A8, A10 and A12 failed to include needed interventions to adequately address the patients' identified problems, or listed intervention modalities that did not reflect the patient's current clinical status and treatment needs (e.g., interventions were not updated as needed). These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed. (Refer to B122)

VI. Provide and document all intervention modalities specified in the Master Treatment Plans, or revise the plans as appropriate for 6 of 12 active sample patients (A1, A2, A3, A7, A9 and A11). Many of the intervention modalities listed in the treatment plans for these patients were not documented in the patient's medical record progress notes. These patients also had low participation levels in the documented interventions, and there was no evidence of alternative activities being offered. Failure to revise or follow the treatment team's plan for active treatment can result in lack of patient improvement and prolonged hospitalization. (Refer to B125-I)

VII. Provide interpreter (sign language) services to assure active treatment for 1 of 12 active sample patients (A3). This patient had a hearing impairment which required interpreter services. These services were not provided on week-ends and were not routinely obtained for the patient's assigned treatment groups. Failure to provide needed translator services for hearing impaired patients results in these patients not obtaining all needed interventions for recovery, potentially prolonging hospitalization. (Refer to B125-II)

Based on record review and interview, the facility failed to ensure that the social work assessments for 10 of 12 sample patients (A2, A4, A5, A6, A7, A8, A9, A10, A11, and A12) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring seamless re-entry into the community.

Findings include:

A. Record Review

The psychosocial assessments (Social Service Reports) of the following patients were reviewed (dates of evaluations are in parentheses): A2 (5/03/10-most recent annual update); A4 (4/15/10); A5 (1/25/10); A6 (5/12/10); A7 (3/23/10); A8 (6/14/10); A9 (3/02/10-most recent annual update); A10 (3/23/10-most recent annual update); A11 (1/09/2010); and A12 (3/16/10-most recent annual update). This review revealed:

1. Patient A2: This patient, admitted on 4/16/09, is a Vietnamese man who remains quite mentally disorganized and was judged as so psychotic as to be non-restorable and incompetent to stand trial, as documented in the Annual Psychosocial Assessment dated 5/03/2010. Despite documenting the patient as non-restorable in this annual update, the social worker wrote in the "Recommendations of Treatment Plan" section of the report "The patient will continue attending one-to-one RTC [restoration to competency] classes. The patient will be encouraged to attend more groups and participate into [sic] this treatment." No additional information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered during this man's prolonged inpatient stay were provided.

2. Patient A4: The "comprehensive psychiatric exam" documented social, legal (robbery charges, competency restoration admission), and personal history (deaf) problems; however, no specific information on discharge alternatives, or areas in need of exploration for the purposes of discharge planning, or other social work interventions were noted in the psychosocial assessment related to the areas noted in the psychiatric exam. In the section "Preliminary Discharge Plan," the social worker wrote, "Depending on the outcome of legal issues, patient will be referred to case management services, an assistant will be provided with the patient's cooperation in applying for benefits if patient meets qualification."

3. Patient A5: In the section "Recommendations for Treatment," the social worker wrote, "The patient is to participate according to the treatments and behavioral plan." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

4. Patient A6: In the section "Social Work Interventions," the social worker wrote, "We will assist in discharge planning. Based on the discharge planning evaluation, the patient will have the following post discharge needs: benefits, housing, case management, medication monitoring and recovery programming." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

5. Patient A7: In the section "Social Work Interventions," the social worker wrote, "To assist with discharge planning. Based on discharge planning evaluation, the patient will have the following post-discharge needs: Benefits, housing, case management, medication monitoring and management, and recovery programming." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

6. Patient A8: In the section "Social Work Interventions," the social worker wrote, "Discharge planning." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

7. Patient A9: In the "Recommendations for Treatment Plan" section of the annual social work update, the social worker wrote "Continue plan and interventions as listed above." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated in the report.

8. Patient A10: In the "Recommendations for Treatment Plan" section of the annual social work update, the social worker wrote "Social worker will encourage the patient to participate in groups in (sic) the unit and will continue to encourage the patient to take an active role in her treatment." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

9. Patient A11: In the "Social Work Interventions" section of the admission social
Service report, the social worker wrote, "Social worker will collaborate with case management agency and also with the patient's legal guardian in assisting with community re-entry plan." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

10. Patient A12: In the "Recommendations for Treatment Plan" section of the social work annual update, the social worker wrote "No additional recommendations at this time. Social worker will continue to support the patient's participation in her treatment plan including medication compliance and participation on unit and recovery mall groups. Social worker will also support the patient's participation in one-on-one counseling. Social worker will support and provide services for the patient's treatment plan as the patient becomes discharge-ready (including referring the patient for benefits as appropriate)." No specific information on discharge alternatives or areas in need of exploration for the purposes of discharge planning or other social work interventions to be offered based on the patient's unique clinical presentation, or her unique social and personal history were delineated.

B. Staff Interview

In an interview with the Director of Social Work on 6/15/10 at 12:04 p.m., the Director stated, "Not enough is mentioned as specific social work interventions for inclusion in the treatment plan."

Based on record review and interview, the facility failed to ensure that a neurological examination was recorded at the time of the admission physical examination for 1 of 12 sample patients (A11). The absence of this information potentially prevents the treatment team from addressing patient physical health needs during the course of hospitalization and from developing patient-specific physical health referrals as components of the discharge plan which ensure appropriate attention to the patient's ongoing physical health needs upon re-entry into the community.

Findings include:

A. Record Review

The admission History and Physical Examination report for A11 did not contain a completed neurological screening examination.

B. Staff Interview

An interview was held with the Medical Director on 6/16/10 at 7:45AM. The admission History and Physical Examination report for A11 was discussed. The Medical Director concurred that the neurological examination had not been recorded for this patient.

Based on record review and interview, the facility failed to ensure that psychiatric evaluations (Comprehensive Psychiatric Exams at admission and annually thereafter) included an inventory of the patients' assets in descriptive, not interpretive fashion for 6 of 12 active sample patients (A2, A4, A5, A7, A8 and A11). The psychiatric evaluations for these patients listed general traits and/or natural/environmental supports as assets, rather than specific attributes possessed by the individual. These failures diminish the ability of the attending psychiatrist to guide the treatment team in recommending and implementing effective treatment interventions based on the personal factors that tend to encourage compliance and capitalize on known strengths.

Findings include:

A. Record Review

1. Patient A2: The admission psychiatric evaluation did not include an inventory of patient assets. There was no inventory of strengths that could be used to help the patient address her presenting problems during hospitalization. The annual update's section (most recent annual update 4/09/10) "Assets and Strengths" stated "The patient is compliant with medications. He is in general pleasant, likeable, quiet, and docile on the unit most of the time. He has supportive case management." These are not personal strengths that could be used to help the patient address his presenting problems or actively or enthusiastically participate in recommended treatment during the hospitalization.

2. Patient A4: The admission psychiatric evaluation (4/14/10) did not include an inventory of patient assets. There was no inventory of strengths that could be used to help the patient address her presenting problems during hospitalization.

3. Patient A5: The section "Assets" in the admission psychiatric evaluation (6/18/09) stated, "[Name of patient] did show some improvement, despite being treatment resistant with several medications. It is possible that she may show further improvement with medications of similar structure to Prolixin." These are not personal attributes or assets that could be used to help the patient address her presenting problems during hospitalization.

4. Patient A7: The section "Assets" in the admission psychiatric evaluation (3/23/10) stated "He has a high school degree. He has case management." Case management is not a personal attribute or asset that could be used to help the patient address her presenting problems during hospitalization.

5. Patient A8: The section "Assets" in the admission psychiatric evaluation (6/13/10) stated, "The patient has apparently (sic) parents who are supportive. He remarked after questioning that he never attempted to harm his parents....It is unclear (sic) the balance of the community support that may be available to him. He has a history of being partially compliant with taking his outpatient medications...." These observations are not personal attributes or assets that could be used to help the patient address her presenting problems during hospitalization.

6. Patient A11: The section "Assets" in the admission psychiatric evaluation (1/08/10) stated, "The patient was recently admitted to Summit around June of 2009 [referring to a previous admission]. He was stabilized on antipsychotic medications and a mood stabilizer and it is believed that he may again reach a state of mental stability when he has been treated again for his mental illness." These comments and observations are not personal attributes or assets that could be used to help the patient address her presenting problems during hospitalization.

B. Staff Interview

An interview was held with the Medical Director on 6/16/10 at 7:45 AM. The admission and annual psychiatric evaluations were discussed. The Medical Director concurred that most of the evaluations did not contain an inventory of patient assets that could be used to guide treatment planning recommendations.

Based on record review and interview, the facility failed to provide comprehensive Master Treatment Plans (MTPs) with all necessary elements for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). The MTPs were missing components such as: 1) patient strengths (Refer to B119); 2) substantiated diagnoses (Refer to B120); 3) observable and/or measurable short term goals with specified target dates (Refer to B121); individualized treatment interventions and modalities (Refer to B122); and/or 4) specific names of staff responsible for the interventions (Refer to B123). Failure to develop treatment plans with all components hampers staff's ability to provide coordinated multidisciplinary care, potentially resulting in patient's treatment needs not being met.

Based on record review, observation and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient strengths for 11 of 12 sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11). The MTPs incorrectly listed external resources (such as "supportive family") as patient strengths and/or failed to specify how patient strengths/assets could be used to support treatment. Failure to identify and incorporate patient strengths in the treatment plan diminishes the effectiveness of treatment interventions, and can hamper patient's achievement of their treatment goals.
Findings include:

A. Record Review

1. Summit Behavioral Healthcare policy "Treatment Planning and Documentation" (BHO Policy CLIN-109, dated 3/05/07), states on page 4: "5. The CTP (Comprehensive Treatment Plan) will include: ...d. A list of identified patient abilities, strengths, preferences, and a statement of how they will be utilized in achieving patient goals." On page 6, the policy also states "5. Prior to completion of the Treatment Plan update, the Treatment Team will also complete a review of: ...e. Strengths and assets not previously noted since the development of the last CTP."

2. Review of the sample patient's MTPs (dates in parentheses) revealed the following:

a. Patient A1. The patient's last MTP update (6/9/10) listed a patient strength as "Able to voice needs." There was no statement of how this strength could be used to help the patient achieve the treatment goals. This patient had been hospitalized since 12/16/09, yet there was no other mention of patient strengths on the MTP.

b. Patient A2. The patient's last MTP update (6/7/10) only listed "Good health" as a patient strength. There was no explanation of the meaning of the phrase "good health" or how it related to the MTP goals. This patient had been hospitalized since 4/16/09, yet the MTP revealed no incorporation of patient's strengths.

c. Patient A3. The patient's last MTP update (5/23/10) listed external resources (e.g., "supportive mother"; "GCB [sic] deaf team case management," and "SSI") as patient strengths. The only other strength listed for the patient, hospitalized since 12/16/09, was "high school graduate." There was no explanation of how the patient's education was to be used in treatment.

d. Patient A4. The patient's last MTP update (5/30/10) listed the external resources "Lives with family at relatives [sic] home"; and "mother is guardian" as patient strengths. The patient had been hospitalized since 4/14/10, yet the MTP contained no identification of the patient's personal strengths.

e. Patient A5. The patient's last MTP update (5/26/10) listed patient strengths as "Educational [sic]" (no further explanation); "College Coursework" (no specification of how it would be used in treatment); "Supportive Family" (external resource) and "Financial Resources" (external resource). There was no explanation of how the patient's education or the resources could help the patient achieve the listed treatment goals. This patient had been hospitalized since 6/19/08, yet the MTP contained no further references to patient strengths.

f. Patient A6. The patient's last MTP update (6/2/10) listed only "Patient is essentially healthy." There was no explanation of what this meant or how it could help the patient achieve the treatment goals.

g. Patient A7. The patient's last MTP update (6/15/10) listed the external resources "CM (Case Manager) with GCB (Name of Agency)" as a patient strength. There was no further identification of strengths on the treatment plan.

h. Patient A8. The patient's MTP (6/15/10) only listed "some family support" as a patient strength. Family support is an external resource, not a personal strength/asset that the patient brought to treatment.

i. Patient A9. The patient's MTP (5/17/10) only listed "Compliant with medication." There was no indication of how this strength was to be used to support the treatment plan. There were no other patient strengths mentioned in the plan, despite the fact that the patient been hospitalized since 2/9/05.

j. Patient A10. The patient's MTP (6/3/10) only listed "verbal." There was explanation of how this strength could be utilized to support the treatment plan. There were no other references to patient strengths in the treatment plan, despite the fact that the patient had been hospitalized since 2/5/04.

k. Patient A11.The patient's latest MTP update (5/23/10) listed the external resource, "Family Support," as a patient strength. There were no other references to patient strengths/assets in the MTP, even though the patient had been hospitalized since 1/8/10.

B. Observation

Observations of treatment team meetings on 6/15/10 on Units F, G, and I between 9:00 a.m. and 10:45 a.m. revealed no staff discussion of patient strengths/assets or how these could be incorporated into the treatment plans and/or treatment plan updates.

C. Interview

1. In an interview on 6/15/10 at approximately 1:30 p.m., the Director of Nursing acknowledged that many of the "strengths" listed on the sample patient's MTPs were not personal patient strengths/assets that could be used to help the patients achieve their treatment goals. She stated "We need to do better with this."

2. An interview was held with RN6 on 6/15/10 at 7:30 p.m. concerning patient strengths described in the treatment plan of active sample patient A6, When the surveyor asked "Do you think the team has adequately identified strengths possessed by A6 that can be used to promote her participation in treatment and recovery," RN6 responded "Not completely....They could identify and use her love of writing better, especially around coping skills."

Based on record review and interview, the facility failed to develop a Master Treatment Plan that included a substantiated diagnosis that served as the primary focus for treatment for 1 of 12 active sample patients (A8). The MTP for this patient did not list any Axis I diagnoses, even though these had been identified in the previous assessments. This deficient practice potentially compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Summit Behavioral Healthcare policy "Treatment Planning and Documentation" (BHO Policy CLIN-109, approved 6/05/08), states on page 3: "1. The Comprehensive Treatment Plan will be developed...within seventy-two (72) hours of admission." On page 4, Item 5, the policy states that the CTP will include: "a. DSM-IV (Axis I-V Diagnoses)" and "b. Diagnostic substantiation..."


B. Patient A8 was admitted 6/13/10. A progress note written by the patient's attending psychiatrist, MD4, on 6/14/10 at 9:25 a.m. stated "Chart reviewed; case discussed with team members; patient seen and evaluated." The progress note included the following Axis I-V diagnoses: "Axis I: Intermittent Explosive Disorder (by history);" "Axis II: Mild Mental Retardation;" "Axis III: Obesity, GERD [Gastroesophageal Reflux Disease], Sinus Allergies, Constipation;" "Axis IV: Recent Move (moved from parents' home to group home), Unemployment;" "Axis V: 20 (functional status rating)." Another progress note, written on 6/15/10 at 8:35 a.m. by MD 4, stated, "Case reviewed. Discussed with unit staff...." This progress note listed the same diagnoses as those on the 6/14/10 progress note.

C. Review of Patient A8's MTP provided by the facility and dated 6/15/10 at 10:00 a.m., revealed no DSM-IV Diagnoses on the written treatment plan. Under the item "AXIS," the MTP only said "Diagnosis Deferred on Axis I."

D. In an interview on 6/15/10 at approximately 10:45 a.m., when asked why a substantiated diagnosis was not entered on Patient A8's MTP despite documentations of Axis 1-V diagnoses in the psychiatrist progress notes, MD 4 (the patient's attending psychiatrist) did not have an explanation.

E. Review of Patient A8's medical record on 6/16/10 at 9:30 a.m. again revealed no substantiated diagnoses on the written treatment plan. At this time, the patient had been on the unit for 74 hours, 20 minutes. Thus, the medical record did not meet the hospital policy requirement for a CTP (Master Treatment Plan) with all required components by 72 hours after the patient's admission.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that included long term and short term goals stated as measurable behaviors with specific target dates for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, and A12). In addition, some of the listed goals for patients A2, A3, A4, A5, A6, A7, A8, A9, A10 and A11 were stated as staff goals for patient participation in program activities (rather than patient behavioral outcomes) or were staff interventions, incorrectly identified as patient goals. Failure to develop clear patient goals with expected dates for goal achievement hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment. This potentially results in prolonged hospitalizations.

Findings include:

A. Record Review

1. Summit Behavioral Healthcare policy "Treatment Planning and Documentation" (BHO Policy CLIN-109, dated 3/05/07), states on page 2: "V. SUBJECT CONTENT: ...The plan (MTP) will include goals and objectives that are measurable and stated in behavioral terms, which will assist the patient in obtaining recovery/treatment goals." On page 4, the policy states "5. The CTP (Comprehensive Treatment Plan) will include: ...h. Individualized patient objectives, written in measurable and behavioral terms, including a target date for completion...."

2. Review of the sample patients' MTPs (dates in parentheses) revealed the following;

a. Patient A1. (MTP update 6/9/10) For the problem "Thought/Mood Disorder," a long-term goal was "Mr. [name] will...exhibit decreased symptoms and be able to function on the unit" (not measurable); a short term goal/objective was "Mr. [name] will verbalize improvement of his symptoms of mood disorder." (not measurable).

The listed target dates for goals related to problems 1, 2 and 3 were 4/20/10 (1 ½ months prior to the 6/9/10 MTP update). Thus, the target dates were not revised at the CTP review.

b. Patient A2. (MTP update 6/7/10). For the problem "...psychotic disorder with...hallucinations and disorganized thinking...," the long-term goal was "will recognize reality such that he can function in a less restrictive environment" (not measurable). The short term goals/objectives "will function with minimal interference from hallucinations, delusions, paranoia in the area of daily living" and "will communicate appropriately AEB articulating answers to questions without redirection from staff," also were not measurable. Another short-term goal/objective on the MTP was "[name] will identify at least one appropriate housing option in the community." This is a staff goal/intervention, not a goal for patient achievement.

The listed target dates for the short-term goals/objectives related to problems 1, 3, 4 were 4/17/10 (prior to the 6/7/10 MTP update). The target date for the short-term goal/objective "[name] will participate in Conditional Release Planning" (related to court hearing for competency) was listed as 4/9/11 (not a short-term goal). The target date for the goal "[patient's name] will be able to communicate needs to staff," (patient was Vietnamese and English was second language), was listed as 2/3/11. However, the 6/7/10 MTP update note also stated "Verbally communicates in English when he has needs or desires to be met." Thus the patient goal was already achieved.

c. Patient A3 (MTP update 5/23/10). Non-measurable goals/objectives for this hearing-impaired patient were: "[Patient] will become competent to stand trial"; "[Patient] will have ways to adequately communicate with staff members"; "[Patient] will recognize reality such that he can function in a less restrictive environment" and "[Patient] will function with minimal interference from unstable mood and poor impulse control." Other listed "goals/objectives" were staff goals or interventions rather than patient behavioral outcomes. These were: "[Patient] will receive education regarding the nature and objectives of legal proceedings...have accommodations for his hearing impairment...develop a Discharge Plan to support his recovery in the community."

The target dates for patient achievement of the stated goals/objectives were missing, incorrect, or unrealistic. The specified target date for the goal "receive education regarding...legal proceedings" was 4/26/10 (prior to the MTP update). The target date for other goals on the plan was 12/16/10; this was too far in the future for meaningful assessment. There was no target date for the listed OT goal. The MTP update notes also documented that some of the listed goals had already been met; yet these goals were not revised or deleted from the plan.

d. Patient A4 (MTP update 5/30/10). The long-term goal for the problem "...behavioral difficulties...ADHD (Attention Deficit Hyperactive Disorder) and mild MR (mental retardation)" was "To eliminate behavioral difficulties....will have eliminated the defiant behavior" (not measurable). The short-term goal/objective was "[Patient] will demonstrate appropriate interactions with others and maintain safe and respectful behavior" (not measurable). Staff goals/interventions, incorrectly listed as patient goals/objectives, were "...education regarding the nature and objectives of legal proceedings..."; "...develop a Discharge Plan..."; and "...identify needs/resources to support recovery in the community."

The target dates for short-term goals related to listed problems 1, 4 and 5 were missing. Those for the short-term objectives related to Problem 2 (need to work toward completion of high school education) and Problem 3 (defiant behavior related to ADHD) were listed as 4/14/11. This date was too far in the future for meaningful evaluation of patient achievement of a short-term goal.

e. Patient A5 (MTP update 5/26/10). Non-measurable goals/objectives on the plan included: "[Patient] will recognize reality such that she can function in a less restrictive environment" and "[Patient] will function with minimal interference from paranoia and disruptive behaviors." A staff goal/intervention, incorrectly listed as a patient goal, was "[Patient] will identify needs and resources needed to support her recovery in the community." Another listed short term goal/objective was "[Name] and guardian will be involved in patient's care and will continue to manage her affairs in order to provide the best care possible for the patient." This was not a patient goal.

The MTP update included no target dates for goals/objectives related to listed problems 1-5. The target date for goals related to problem 6 (involvement of persons related to guardianship for the patient) was 10/15/10. This date was too far in the future for meaningful assessment of short term goal achievement.

f. Patient A6 (MTP update 6/2/10). Non-measurable goals/objectives on the plan were "Ms [patient] will recognize reality such that she can function in a less restrictive environment" and "Ms [patient] will function with minimal interference from delusions, paranoia in the area of activities of daily living." Staff goals/interventions, incorrectly listed as patient goals were "Ms [patient] will identify needs and resources to support recovery in the community"; "Ms [patient] will be referred to a provider for ongoing management of [physical problem] as appropriate" and "Ms [patient] will be followed by Dr. [physician name] for ongoing management of hyperlipidemia...."

There were no target dates listed for any of the long term or short term goals on the treatment plan.

g. Patient A7 (MTP update 6/15/10). Non-measurable goals/objectives on the plan were "[Patient] will recognize reality such that he can function in a less restrictive environment" and "[Patient] will function with minimal interference from auditory hallucinations, paranoid delusions, decreased self care, and aggressive behavior in the community." Staff goals/interventions, incorrectly listed as patient goals or objectives were "Mr. [patient] will be refereed (referred) to SBH physician for ongoing management of his COPD (Chronic Obstructive Pulmonary Disease)"; "Mr. [patient] will be referred to SBH physician for ongoing management of hyponatremia (electrolyte imbalance/low serum sodium level)" and "Mr. [patient] will identify needs/resources of case management and outpatient therapy to support recovery in the community."

h. Patient A8 (MTP 6/15/10). For the identified problem "Intermittent Explosive Disorder..." the listed long term goal was "Mr. [patient] will recognize reality such that her [sic] can function in a less restrictive environment." The short term goal/objective was "Mr. [patient] will function with minimal interference from aggressiveness and assaultiveness." As stated, neither of these goals/objectives were measurable patient behaviors. The short term objective for the identified problem "Mr. [patient] needs to develop a discharge plan," was "Mr. [patient] will identify needs/resources such as case management to support recovery in the community." Discharge planning is the responsibility of the social work staff, not the patient.

The target date set for the patient's achievement of the short term goal for discharge planning was 6/30/11. This date was too far in the future for a meaningful evaluation of goal achievement. The expectation for the patient to be actively involved in discharge planning while he still had aggressive behaviors that required 1:1 nursing observation and restraint and seclusion (S/R daily from 5/13/10 to 5/15/10) was unrealistic.

i. Patient A9 (MTP update 5/17/10). Non-measurable goals/objectives on the treatment plan were [Patient] will recognize reality such that he can function in a less restrictive environment" and "[Patient] will function with minimal interference from Specify [sic] hallucinations, delusions, paranoia." A staff goal, incorrectly listed as a patient goal, was "[Patient] will identify needs/resources to support recovery in the community."

j. Patient A10 (MTP update 6/3/10). For the problem "Thought Disorder..." the long term goal was "[Patient] will recognize reality as such that she can function in a less restrictive environment." The short term goal/objective was "[Patient] will function with minimal interference from delusions, paranoia, hallucinations and mood instability by demonstrating safe and appropriate behaviors" and "Pt [patient] will demo [demonstrate] increased concentration AEB [by] utilizing tx [treatment] mall schedule to attend tx mall groups" (OT goal). As stated, these goals were not measurable patient behaviors. Staff goals/interventions, incorrectly listed as patient goals were "[Patient] will identify needs/resources case management services [sic], finances and housing to support recovery in the community"; "[Patient] will be referred to a provider for ongoing management of her [physical problem]"; "[Patient] will receive medical treatment to manage her [physical problem] as needed" and "[Patient] will be referred to a provider or ongoing management of her cardiovascular condition as needed."

The target dates listed for the patient's participation in planning for her "Conditional Release" from NGRI status (Court required treatment) and discharge from the hospital was 2/8/10. This was four months prior to the MTP update. The listed target date for the OT (Occupational Therapy) short term goal for the patient was 12/15/10. This was too far in the future for meaningful assessment. There were no listed target dates for the medical problems listed on the treatment plan.

k. Patient A11 (MTP update 5/23/10). Non-measurable goals/objectives on the treatment plan were "Mr. [patient] will demonstrate sufficient ability to function in areas of independent living skills to return to the community"; "Mr. [patient] will recognize reality such that he can function in a less restrictive environment"; "Mr. [patient] will have verbalized improvement of his perceptual symptoms"; "[Patient] will be able to demonstrate correct phone usage." Staff goals for patient participation in treatment, incorrectly stated as patient goals (behavioral outcomes) were "Mr. [patient] will identify needs/resources to support recovery in the community"; "Mr.[patient] will participate in recommended treatment and selected mental health recovery groups" and "Guardianship process will be continued for Mr. [patient]" and "Mr. [patient] has appointed a guardian."

The MTP had no listed target date for the goal "correct phone usage" noted above. The target dates listed for short term goals/objectives related to the other listed problems were 1/9/11 or 3/30/11. These target dates were too far away to allow meaningful assessment of the patient's achievement of the goals.

l. Patient A12 (MTP update 5/17/10). Non-measurable goals/objectives for the problem "Psychosis (delusions)" were "Patient will remain in full remission from psychosis" and "Patient will display no signs or symptoms of psychosis."

The target date for the short term objectives on the treatment plan (for all problems) was 2/17/10. This was three months before the CTP update of 5/17/10; thus the dates for patient achievement of the treatment plan goals were not updated at the last CTP review.

B. Interview

1. In an interview on 6/15/10 at approximately 1:30 p.m., the Director of Nursing acknowledged that the long term goals and "objectives" (short-term goals) listed on the sample patients' MTPs were not measurable as written. She also acknowledged that the many of the target dates for patient achievement of short term goals/objectives were either missing or were not realistic or correct target dates.

2. In an interview on 6/16/10 at 9:15 a.m., the Director of OT (Occupational Therapy), after reviewing the MTP for sample patient A10, agreed that the listed OT goal was not measurable as stated, and that the target date of 12/15/10 was not reasonable.

Based on record review and interview, the facility failed to provide Master Treatment Plans that specified the modality, frequency, and duration of all listed interventions for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). The MTP for patient A9 also incorrectly listed "staff goals/interventions" as patient goals. In addition, the MTPs for patients A2, A3, A7, A8, A10 and A12 failed to include needed interventions to adequately address the patients' identified problems, or listed intervention modalities that did not reflect the patient's current clinical status and treatment needs (e.g., interventions were not updated as needed). These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record Review

1. Summit Behavioral Healthcare policy "Treatment Planning and Documentation" (BHO Policy CLIN-109, dated 3/05/07), provides the following description of "treatment intervention" on page 2: "H. Treatment Intervention: A documented therapeutic activity provided by trained/qualified provider(s) to assist the patient in achieving those goals which specifies the duration of the intervention, how often it will be provided, and the focus of the intervention." The policy further states on page 4: "5. The CTP (Comprehensive Treatment Plan) will include: ...h...individualized interventions as indicated, including one to one therapy, group therapy, medication, off unit programming, and other treatment modalities as needed."

2. Review of the sample patients' MTPs (dates in parentheses) revealed the following:

a. Patient A1 (MTP update 6/9/10). The SAMI (Substance Abuse/Mental Illness) intervention to address the patient's lack of awareness regarding the "interaction between alcohol/drugs of abuse with his thought disorder and/or mood disorder..." was "[Staff name] will interact with [patient] weekly along with unit staff/treatment team to build rapport, develop familiarity and assess readiness to talk about SA (substance abuse) and MI (mental illness) issues..." There was no specified modality or duration of the assigned meetings.

b. Patient A2 (MTP update 6/7/10). This patient was a 48 year old Vietnamese male who was admitted to the hospital on 4/16/09 (social work progress note 5/27/10). One of the problems listed on the MTP was "[Patient] requires assistance for verbal communication with staff and peers due to VietNamese [sic] as first language and English as second language." Goals related to the problem were "[Patient] will be able to participate in treatment" and "[Patient] will be able to communicate needs to staff." The only intervention listed on the MTP to address the patient's language barrier was, "All staff will assess barriers and develop ways to communicate with [patient] to assist in meeting his needs."

Documentations in the medical record progress notes (Psychiatry 5/16/10, 6/1/10; OT 5/18/10; Nursing 5/25/10; Social Work 5/25/10; 5/27/10) noted the patient's difficulties communicating with staff and peers, and his lack of active participation in programming. A nursing progress note (5/25/10) stated, "...Patient continues to be difficult to understand when he speaks to staff, is seen as having difficulty in groups with communications issues, and has difficulty with expressing self due to language problems." The 6/7/10 MTP update for the patient stated: "Patient selectively talks to different staff using broken English, and then at other times will talk in his native language...becomes verbally loud using both English and his countries [sic] language..." Another note said, "Verbally communicates in English when he has needs or desires to be met." The MTP update did not mention the need for a language interpreter, nor did it provide any other guidance regarding how staff could facilitate the patient's meaningful participation in treatment.

The MTP for patient A2 also noted "[Patient] has a psychotic disorder with symptoms including audio hallucinations [sic]and disorganized thinking." For the problem "history of assaulting other patients without warning," the interventions were "Will be invited to groups on/off the unit including community meeting, current events, patient empowerment, psychology, sw (Social Work), OT, and nursing groups and show appropriate interactions and boundaries with staff and peers at least 2 x a week for 15 minutes in each group." These group modalities were unrealistic for the patient, given his disabilities and language barriers.

c. Patient A3 (MTP update 5/23/10). This "deaf" patient had been hospitalized since 12/16/09. The only intervention listed on the MTP to address his hearing impairment was "All staff will communicate with [patient] by writing to him and/or sign language for ongoing management of his hospital treatment..." The MTP included group therapies and activities (RTC; community meetings; medication education; OT) as well as 1:1 interventions. The Treatment Mall "Patient Program Hours Report" for May 2010 showed that the patient only attended 50% of the assigned groups. Most of these groups were physical activities (sports, Tai-Chi, OT exercise sessions). The only hearing "interpreter" services he received was for weekly 1:1 RTC (Restoration to Competency) sessions [patient declined the assigned group sessions] and for a psychological testing session (data from progress notes reviewed for 5/14/10 - 6-14-10).

The social work intervention to address the patient's discharge planning needs read "Social worker will encourage Mr. [patient] to involve support system in his treatment..." There was no specified modality or duration for the assigned intervention.

A psychiatrist progress note written 6/2/10 read "Pt [patient] continues to have problems [sic] with boundaries with female clients...in Sunday OT group, pt was noticed sitting close to mentally retarted [sic] female cl [sic] from D (Unit)...female cl [sic] was sitting in his lap...when tried to redirect, he became angry, irritable, making gestures..." "Pt had psych testing...which indicated Mild MR" [sic]. The psychiatrist note included a "plan" for the patient to have a "sign language interpreter" for 1:1 and group sessions. As of 6/14/10, the MTP had not been updated to include the recommended interpreter services.

d. Patient A4 (MTP update 5/30/10). The listed intervention for the patient's substance abuse problem was "SAMI (Substance Abuse/Mental Illness) counselors will interact with Mr. [patient] twice a week along with unit staff/treatment team, to build rapport, develop familiarity and assess readiness to talk about SA and MI issues." There was no specified modality or duration for the assigned intervention.

e. Patient A5 (MTP update 5/26/10). The following intervention was listed to address the patient's ADL [activities of daily living] needs, "TPW (Trained Psychiatric Worker) staff will provide independent living skills training daily specific to [patient] to increase independent living in the community." It was unclear what modality (group/individual) was to be used. The duration of the sessions also was not specified. There were no listed social work interventions on the treatment plan. For the patient's discharge planning, the MTP stated: "The Treatment Team will meet with [patient] monthly or more often as needed to encourage and talk about recovery needs and progress so she will be able to tell staff about progress in her recovery." It was unclear whether the social work staff was to carry out this intervention.

Review of the May/June 2010 progress notes and the "Patient Program Hours Report" for Mall programming showed that Patient A5 was not attending several of the intervention modalities specified in her treatment plan but that she was engaged in other on-unit and off unit (Mall) therapies (e.g., "Leisure/Recreation"; "Women's Wellness"; "Meditation"; "Journaling"; "Medication Education"; "Health Issues"; and "Just for Today" groups). The written MTP had not been updated to include these changes.

f. Patient A6 (MTP update 6/2/10). The following listed interventions had no specified modalities, frequency of sessions, or duration of the sessions: "Unit E staff will educate [patient] about mental illness and have her discuss what she has learned to show her understanding"; "Unit Social Worker will encourage [patient] to participate in on-unit social work groups to learn about community resources and the discharge planning process"; "Unit RN will meet with [patient] as needed to assess condition and educate regarding needs and educate on precautions (infection control)..." A following physician intervention also had no specified frequency: "Dr [physician] will also order diagnostic tests as appropriate to examine and monitor issues with increased lipids."

g. Patient A7 (MTP update 6/15/10). This patient was admitted on 3/23/10 with a "psychotic disorder with symptoms including auditory hallucinations, paranoid delusions, decreased self care, and aggressive behavior which requires hospitalization" (documentation on 6/15/10 MTP update). Interventions on the MTP to address this problem included 1:1 sessions as well as numerous group modalities: "weekly Psychology group"; "Unit F Recovery Check-in"; "Gateway to Recovery group"; "SRT group"; "Discharge group"; "Medication Education group"; "Healthy Issues group"; "OT Engagement group." Review of progress notes in the patient's medical record from 5/16/10 thru 6/15/10 revealed that the patient did not attend most of the group sessions. The 6/15/10 MTP progress note said the patient was only attending an "on unit discharge group" and an "off unit library group." Despite evidence that the patient was not adequately engaging in the assigned groups, the MTP was not modified to provide more 1:1 or other alternative treatment modalities/activities.

h. Patient A8 (MTP 6/15/10). According to the MTP, this patient (admitted to the hospital on 6/13/10), had "a psychotic disorder with symptoms including assaultiveness, aggressiveness and impulsivity that requires hospitalization." Review of the patient's medical record progress notes revealed that, since the patient's admission, he had multiple episodes of aggression that required emergency medications and Seclusion and Restraint orders (for manual holds). Interventions listed on the MTP to address his Problem #1: "Intermittent Explosive Disorder/Engagement" were: "Unit psychiatrist" - "weekly psychotherapy or 15 minutes and prescribe the appropriate medication"; "Unit Psycholosist" - "weekly psychology group"; "Unit F Recovery Check-In"; "Unit psychologist and SAMI Staff" - "Gateway to Recovery group"; "Unit RN's" - "Healthy Issue group"; "Unit LPN's" - "Med Education group." The group modalities were inappropriate for the patient's current clinical status.

The following interventions to address the patient's symptoms of psychosis were missing the frequency of duration of the intervention: "Unit Psychologist and Unit SAMI Staff will also provide Gateway to Recovery group." "Unit RNs will provide RN Healthy Issue group. Unit LPNs will provide Med Education group."

i. Patient A9 (MTP update5/17/10). A listed intervention to address the patient's need for discharge planning read: "[Patient] will cooperate with the legal requirements involving court hearing and froensic [sic] reviews to gain an increase in privileges." This is a patient goal, incorrectly listed as a staff intervention.

j. Patient A10 (MTP update 6/3/10). The following intervention to address the patient's legal status had no specified modality: "Unit H Staff will meet with [patient] 15 minutes weekly and as often as needed to provide education and information on Conditional Release Plan."

Review of progress notes in the patient's medical record (5/15/10 thru 6/14/10) and the May/June 2010 "Patient Program Hours Report" for Mall Treatment groups revealed that the patient was attending several groups that were not listed as interventions on the MTP. Some of these groups were special groups for women, e.g., "Fitness for Women"; "Family Issues"; and "Responsible Adult Development for Women." The patient also had a work assignment in the clothing room (Adjunctive Therapy progress notes 6/1/10; 6/3/10). The MTP was not updated to reflect these changes.

k. Patient A11 (MTP update 5/23/10). The MTP failed to specify the modality, frequency, and/or duration for the following staff interventions: "[Staff name] Social Work will encourage [patient] to participate in discharge planning activities..."; "[Staff name] Social Work & [SAMI staff name] will encourage [patient] to participate in Recovery and Wellness Groups...."

l. Patient A12 (MTP update 5/17/10). The following interventions had no modality, frequency or duration specified: "Pt will meet with unit social worker as required to discuss conditional release planning"; "Pt will meet with unit nurse to discuss tx [treatment] needs"; "Pt will meet with unit nutritionist as reuqired [sic] to discuss dietary needs"; "Pt will meet with unit medical doctor as required to discuss various needed treatments"; "Pt will meet with unit social worker and psychologist as required to discuss treatment planning, relapse prevention, and conditional release planning"; "Pt will meet with unit psychiatrist to monitor status and discuss medication needs."

The patient was no longer attending some of the interventions listed on the MTP; however, she was actively engaged in other treatment groups which were documented on the Treatment Mall Patient Program Hours Report. The 5/17/10 MTP update progress note acknowledged the patient's progress but the listed MTP interventions had not been modified to reflect the patient's current treatment.

B. Staff Interviews

1. In an interview with MD2, RN3, SW2, and OT1 on 6/15/10 at 10:00 a.m., the treatment plan review/update for active sample patient A2 was reviewed. Five (5) interventions across two (2) problems were listed as meetings with the treatment team. The surveyor inquired whether the team considered treatment team meetings as "specific treatment modalities/interventions." After some consideration, MD2, RN3, SW2, and OT1 agreed that a treatment team meeting "is not a specific treatment intervention."

2. In an interview on 6/15/10 at approximately 10:45 a.m., MD 4 (patient A7's attending psychiatrist) acknowledged that some of the modalities on patient's A7's treatment plan were not realistic for him, given his current functioning. He also said that the MTP did not adequately reflect the 1:1 time he actually spent with the patient (plan said only 15 minutes per week).

3. In an interview with RN5 on 6/15/10 at 6:40 p.m. active sample patient A5's treatment plan was reviewed. The surveyor asked RN5 if he could locate any specific social work interventions on the plan. RN5 stated, "I don't see any."

Based on record review and interview, the facility failed to specify the names of staff responsible for interventions on the Master Treatment Plans (MTPs) for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). Many of the interventions for these patients only listed responsible disciplines instead of specific staff names. Failure to specify the names of responsible staff for interventions diffuses responsibility and can result in patient's treatment needs not being addressed.

Findings include:

A. Record Review (MTP dates in parentheses)

1. Patient A1 (MTP update 6/9/10). The MTP did not include the names of staff responsible for 5 of the 6 staff interventions listed for the problem "Thought/Mood Disorder." Instead of staff names, the MTP listed the following disciplines for assigned treatment groups: "Psychology staff" - "Personal Empowerment Program"; "Responsible Adult Development (RAD) group." "OT staff" - "OT Workshop." "Unit A [nursing] staff" - "Community Meeting"; "Patient Empowerment for Recovery Group."

2. Patient A2 (MTP update 6/7/10). The MTP was missing the names of responsible staff for 2 of the interventions listed for the problem "Psychotic Disorder..." Instead of staff names, the MTP listed the following disciplines with no staff names for the assigned interventions: "OT" - "Leisure Exploration Group"; "OT and Nursing Staff" - "Patient Empowerment group." For the patient's communication problem related to "English as a second language," the intervention said, "All staff will assess barriers and develop ways to communicate with [patient] to assist in meeting his needs."

3. Patient A3 (MTP update 5/23/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Forensic staff" - "RTC (Restoration to Recovery) group"; "TPWs (trained psychiatric worker)" - "Community Meetings"; "LPNs" - "Medication Education group"; "Social Worker" - "Tai-Chi group"; "SAMI staff" - "substance abuse" Rx (1:1 and group,)

4. Patient A4 (MTP update 5/30/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "RTC Counselor" - "educate [patient] about court procedures"; "Education Staff" - "involve [patient] in scheduled computer classes"; "Psychologist" - "Responsible Adult Development group"; "Social Worker" - "Assertiveness Group"; "Librarian" - "Library Group"; "SAMI Counselors" - "interact with [patient] twice a week...to assess readiness and talk about SA (substance abuse) and MI (mental illness) issues"; "What Can I Do" group; and "Biology and Behaviors of Use" group.

5. Patient A5 (MTP update 5/26/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Unit Psychiatrist" - "meet with [patient] (1:1) weekly"; "OT staff " - "Patient Empowerment for Recovery"; "Daily Living Skills" groups; "Nursing" - "Walking for Wellness" group; "Unit Psychologist" - " meet with patient (1:1) weekly"; "develop/revise Behavior Plan"; "SAMI (Substance Abuse/Mental Illness) staff" - "SAMI Basics"; "Sobriety & Leisure"; "Living Stories"; "Coping with Stress and Barriers to Recovery" groups; "TPW staff" - "provide independent living skills training daily." There were no listed social work interventions on the treatment plan.

6. Patient A6 (MTP update 6/2/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Unit E [nursing] Staff" - "Patient Empowerment Group"; "Community Meeting"; "Current Events Group"; "Exercise Group"; "Gross Motor Group (exercise)"; "Leisure Exploration Group"; "Modified RAD Group/Promoting Responsible Adult Development Group"; "Workshop Group"; "Unit LPN" - "Medication Education Group." "Unit Social Worker" - "Social Work Group"; and "Unit RN" - "special precautions for infection control."

7. Patient A7 (MTP update 6/15/10) The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Unit Psychiatrist" - "individual sessions one weekly for 15 minutes"; "Unit Psychologist" - "weekly Psychology Group"; "Unit F Recovery Check-In"; "Psychologist and unit SAMI staff" - "Gateway to Recovery Group"; "Social Worker and SAMI Staff" - "weekly SRT group"; "Social Worker" - "weekly Discharge group"; "Unit LPNs" - "Medication Education group ; "Unit RNs" - "Healthy Issues group."

8. Patient A8 (MTP 6/15/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Unit Psychiatrist" - "weekly psychotherapy sessions"; "Unit Psychologist" - "weekly psychology group", "Unit F Recovery Check-In"; "Unit Psychologist and SAMI Staff" - "Gateway to Recovery group"; "Unit RNs" - "RN Healthy Issue group"; "Unit LPNs" - "Med Education group" and "Unit Social Worker" - "discharge/relapse prevention plan" (individual sessions with patient).

9. Patient A9 (MTP update 5/17/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "TPW Staff" - "Community Meeting"; "Current Events"; "Exercise Group"; "Patient Empowerment for Recovery group"; "LPN/RN staff" - "medication Education group"; "RN staff" - "Symptom Management/Health Issues group."

10. Patient A10 (MTP update 6/3/10). The MTP listed "disciplines" instead of specific staff names as being responsible for the following interventions: "Social Worker" - "Mental Health Readiness group"; "discharge/relapse prevention plan" (individual sessions with patient); "LPN" - "Medication Education Group"; "Staff OT" - "Patient Empowerment Group"; "Daily Living Skills" group. Other group activities conducted on Unit H were assigned to "All Staff" or "Staff."

11. Patient A11 (MTP update 5/23/10). The MTP listed the following "disciplines" instead of specific staff names as being responsible for the interventions: "SAMI staff" - "SAMI Basics group; "Nursing staff" - "Community Meeting"; "Current Events"; "Exercise Group"; " Morning Goal Group"; "Medication Education Group"; "Movie Discussion Group"; "Patient Empowerment for Recovery group"; "OT staff" - "Leisure Exploration Group"; "Psychology Staff" - "Anger Management"; Some additional on-unit activities were assigned to All staff."

12. Patient A12 (MTP update 5/17/10). There was no identified staff for any of the interventions listed on the treatment plan except for individual therapy by the unit psychologist. The following disciplines (with no staff names) were listed as responsible for interventions: "Unit Social Worker"; "Unit Nurse"; "Unit Nutritionist"; "Unit Medical Doctor"; "Unit Psychiatrist"; "Unit J LPN" and "Unit J RN." Some on-unit activities were just assigned to "Unit J Staff."

B. Staff Interview

1. In an interview on 6/15/10 at approximately 1:30 p.m., the Director of Nursing acknowledged that the names of staff responsible for many of the listed interventions on the sample patients' treatment plans were missing.

2. In an interview on 6/16/10 at approximately 9:00 a.m., the Director of OT stated that she did not know why OT staff names were not assigned to OT interventions on the plans.

Based on interviews, observation and record review, it was determined that the facility failed to provide and document active treatment for 6 of 12 active sample patients. Specifically, the facility failed to:

I. Document the provision of intervention modalities specified in the Master Treatment Plans or revise plans as appropriate for 6 of 12 active sample patients (A1, A2, A3, A7, A9 and A11). Many of the interventions assigned by the treatment team and noted in the MTPs were not documented in the patients' medical record progress notes. For interventions which the patients actually attended, medical record documentations and observations revealed that these patients had low participation levels, and there was no evidence that alternative activities were offered. Failure to follow or revise the treatment team's plan for active treatment can result in lack of patient improvement and prolonged hospitalizations.

II. Provide interpreter (sign language) services to assure active treatment for 1 of 12 active sample patients (A3). This patient had a hearing impairment which required interpreter services. These services were not provided on week-ends and were not routinely obtained for the patient's assigned treatment groups. Failure to provide needed translator services for hearing impaired patients results in these patients not obtaining all needed interventions for recovery, potentially prolonging hospitalization.

Findings include:

I. Failure to provide and document appropriate intervention modalities

A. The facility's policy "Treatment Planning and Documentation" (BHO Policy: CLIN-1090), dated 6/5/08) includes the following statement on page 6 under Item D. "Implementation of Treatment Plans - Individual Progress Notes:" "1. Progress notes will be written in chronological order and shall contain a careful assessment of the patient's progress related to problems indicated on the Comprehensive Treatment Plan and its updates....3. Progress notes will include a description of participation in groups and individual sessions, which are included in the CTP."

B. In an interview on 6/14/10 at 10:00 a.m., the Director of Nursing stated that Summit Behavioral Healthcare provides treatment for patients by: 1) a schedule of on-unit programming, specific for each treatment unit, and 2) treatment groups/activities delivered by staff in a "Treatment Mall." The DON said that the Treatment Teams assign patients to specific groups/activities in the Treatment Mall, based on their assessed treatment needs. The on-unit groups/activities are typically open to all patients on the unit. The unit staff monitors patient attendance in the on-unit groups, and writes monthly progress notes, summarizing the patient's participation.

C. In an interview on 6/15/10 at 11:30 a.m., the Director of Clinical Services (who also serves as the Director of Treatment Mall activities) stated that the staff responsible for Mall groups/activities have a list of assigned patients for their groups/activities and the patient's participation in each group is to be documented in the multidisciplinary progress notes.

D. In an interview with SW1, the substitute group facilitator for the treatment mall's "The Best Me I Can Be" group, on 6/14/10 at 3:40 p.m., SW1 stated that he writes "a progress note on each patient" attending his group. He stated that he "has a list of patients referred to the group" for noting attendance. When asked if he was aware of why each patient was referred to the group, that is, what problem, goal, and objective per the treatment plan, SW1 stated "I don't know that...I attempt to find that out by asking each patient questions...it's less a group process than a series of 1:1 interactions." When asked if he reviews each patient's treatment plan for the specific problem, goal, and objective in order to be able to document each patient's progress for the group session, SW1 stated "No, but I could do that." In response to the surveyor's query "But do you do this regularly and routinely," SW1 answered "No, I don't."

E. Specific Patient Findings

1. Patient A1. A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentations for the following on-unit groups specified on the treatment plan: "OT: workshop:"; "TPW: Community Meeting"; "Patient Empowerment & Recreation Group." Weekly summary notes written by the TPW (Trained Psychiatric Worker) for on-unit programming (dated 5/22/10, 5/28/10, 6/3/10 and 6/11/10) stated: "Patient stays by himself...does not attend treatment activities at this time." There was no evidence that alternative interventions were offered to the patient.

2. Patient A2. This patient was a 48 year old Vietnamese male who was admitted to the hospital on 4/16/09 (social work progress note 5/27/10). Documentations in the medical record progress notes (Psychiatry 5/16/10, 6/1/10; OT 5/18/10; Nursing 5/25/10; Social Work 5/25/10; 5/27/10) noted the patient's difficulties communicating with staff and peers, and his lack of active participation in programming. The nursing progress note (5/25/10) stated, "...continues to be difficult to understand when he speaks to staff, is seen as having difficulty in groups with communications issues, and has difficulty with expressing self due to language problems." There was no evidence that an interpreter had been provided to help the patient overcome the language barriers.

The MTP (update 6/7/10) for patient A2 noted that the "[Patient] has a psychotic disorder with symptoms including audio hallucinations and disorganized thinking." Interventions for the problem "history of assaulting other patients without warning," were "Will be invited to groups on/off the unit including community meeting, current events, patient empowerment, psychology, sw (Social Work), OT, and nursing groups and show appropriate boundaries with staff and peers at least 2 x a week for 15 minutes in each group." These group modalities were unrealistic for the patient, given his disabilities and language barriers.

3. Patient A3. This deaf patient was admitted 12/16/09. Review of the multidisciplinary progress notes in the patient's medical record from 5/15/10 through 6/15/10 revealed no documentations for the following interventions assigned by the treatment team (and noted on the MTP update of 5/23/10): "community meetings: 30 minutes 2 x per day (by TPWs)"; "medication education group: 30 minutes 2 x per week (by LPNs); "Leisure Exploration group: 1 hr/week" (OT staff); "Exercise Group: 2 x/week" (OT staff).

Review of the "Patient Program Hours Report" for the Treatment Mall for May 2010 revealed that the patient had only attended 50% of the group sessions that he was assigned to attend. These groups included "Tai Chi"; "Sports and Recreation"; "OT Workshop"; and "Journaling: A Tool for Learning." There was no documentation of alternative activities being provided to the patient. There also was no evidence that the patient received needed interpreter services for his hearing impairment (see B125-II for details).

4. Patient A7. The MTP update of 6/15/10 listed goals: "[Patient] will recognize reality such that he can function in a less restrictive environment" and "[Patient] will function with minimal interference from auditory hallucinations, paranoid delusions, decreased self care, and aggressive behavior in the community." He was assigned a list of on-unit modalities. A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentations for the following on-unit groups specified on the treatment plan: "Unit Psychologist: 1:1 weekly sessions"; "Unit Psychologist/SAMI staff: Gateway to Recovery Group"; "LPN: Medication Education"; "RN: Healthy Issues group"; "OT: Engagement Group." Notes by a TPW (5/19/10). The only activity listed on the "Patient Program Hours Report" (for assigned Treatment Mall activities) was a "Library" group.

The 6/15/10 MTP update progress note stated that the patient was only attending an on unit discharge group and off unit library group. A Social Worker note (5/20/10) documented that the patient did not attend scheduled on-unit groups but was going to the Mall for "socialization." There was no evidence that other alternatives were offered to the patient.

Observations of Patient A7 on Unit F on 6/14/10 (11:00-11:30 p.m.) and 6/15/10 (11:00-11:30 a.m.) revealed the patient sitting by himself at a table in the common area. He sat with his head in his hands and was not interacting with staff or other patients. When approached by the surveyor, he declined to be interviewed.

In an interview on 6/15/10 at approximately 10:45 a.m., MD 4 (patient A7's attending psychiatrist), stated that the patient had been "in and out of the hospital for the past 6 months" with "auditory hallucinations," and that there had been little improvement in his condition. When asked why the MTP included group modalities that the patient could not benefit from and was not attending, MD4 said "all on-unit groups are open to him except for the Friday psychologist group that is by invitation only." MD4 acknowledged that some of the modalities were not realistic for the patient.

5. Patient A9, 2/11/05-admission. The MTP update of 5/17/10 listed the goals/objectives: "[Patient] will recognize reality such that he can function in a less restrictive environment" and "[Patient] will function with minimal interference from specify [sic] hallucinations, delusions, paranoia." Weekly TPW summary notes (5/18/10; 5/27/10) stated that the patient attended groups on and off of the unit. However, there was no documentation regarding the patient's participation in (or response to) these activities or how the activities were helping him achieve his treatment goals.

A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentations for the following groups/activities specified on the treatment plan: "TPW Groups: Community Meetings (30 minutes 1 x/wk), Current Events (30 minutes 2 x/day), Exercise (30 minutes/day), Patient Empowerment for Recovery"; "LPN/RN: Medication Education;" "RN: Symptom Management/Health Issues (2 x/wk)"; "Social Work: Mental Health/Discharge Group 1 hr/wk." A psychiatrist note on 6/1/10 read "He [patient] is willing to allow me to sit next to him and talk to him. Generally looks forward rather than making eye contact but carries on the conversation with me...socially isolated - keeps to himself as he walks or sits. Friendly but uncomfortable in his interactions." Despite evidence of the patient's discomfort in social interactions (documented on MTP updates), there was no documentations of staff attempts to provide alternative activities.

In an interview on 6/14/10 at 12:40 p.m., Patient A9 could not tell the surveyor anything about his treatment. After some incoherent remarks, he terminated the interview.

6. Patient A11 admitted 1/8/10. The MTP update 5/23/10 listed goals/objectives: "Mr. [patient] will demonstrate sufficient ability to function in areas of independent living skills to return to the community"; "Mr. [patient] will recognize reality such that he can function in a less restrictive environment"; "Mr. [patient] will have verbalized improvement of his perceptual symptoms." A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentations for the following on-unit groups/activities specified on the treatment plan: "Social Work" - "Recovery and Wellness Groups"; "Nursing" - "Community Meeting, Current Events, Exercise, Med Education, Movie Discussion, Patient Empowerment"; "OT" - "Leisure Exploration"; "SAMI staff" - "individual sessions weekly for 45 minutes." A nursing progress note written on 6/8/10 said, "Patient attends few groups on/off unit with little participation." A psychiatrist note of 6/10/10 noted that he had "Poor response to most of Tx [treatment]." Despite the patient's lack of response to current treatment, there was no evidence of staff attempts to provide alternative therapies/activities (e.g., more 1:1 interactions).

In an interview on 6/14/10 at 3:00 p.m., Patient A11 was queried about what the staff was doing for him and his goals for his hospitalization. The patient could not describe any staff interventions that were helpful, nor did he know any of his treatment goals. When asked how long he had been in the hospital, he said "Ten years." When asked if that was correct, he said, "Well, it's been about 10 weeks but it feels like 10 years." He said he likes "music" but that the music group that he can attend is "just talk, not any instruments."

A treatment team meeting was observed on Unit I on 6/15/10 from 10:50 a.m. to 11:00 a.m. when Patient A11's treatment plan was discussed. The discussion focused on the patient's current behaviors and desire for discharge from the hospital. When interviewed, the patient denied that he had any problems or need for treatment. There was no specific discussion of the patient's lack of participation in the treatment modalities on the MTP or alternative approaches to engage him in treatment.

II. Failure to provide interpreter services for Patient A3

A. Record Review

1. Pt. A3 was admitted 12/16/09. Problem #2 on Patient A3's Master Treatment Plan (updated 5/23/10) was "[Patient] has a hearing impairment." The long term goal for this problem was "[Patient] will have accommodations for his hearing impairment." The short term goal/objective was "[Patient] will have ways to adequately communicate with staff members and family."

2. A progress note on the 5/23/10 MTP update related to the patient's hearing impairment stated "Pt [patient] meets 1:1 with an interpreter weekly, sometimes for RTC (Restoration to Competency) or psych testing or meet [sic] with a member of his treatment team to discuss his treatment plan. Pt utilizes a writing journal to communicate needs with staff and general conversations."

3. The only progress notes, documenting that an interpreter was immediately available to the patient was a psychologist note of 5/19/10 which stated that the patient was informed of the results of psychological testing with an interpreter present and a nursing note (6/10/10) which said the patient "has been receiving 1:1 RTC (Restoration to Competency) sessions with an interpreter to help better communicate information."

4. A psychiatry progress note written on 6/2/10 stated, "...Pt continues to have problms [sic] with boundaries with female clients. On Sunday OT group, pt was noticed sitting close to mentally retarted [sic] female cl [sic] from D (unit) female cl [sic] was sitting in his lap...pt had psych testing...which indicated Mild MR [Mental Retardation]" The note stated that the patient had been referred to DDS [Developmentally Disabled] services. However, there was no evidence that an interpreter would be made available to the patient for assistance with his behavior control and relationships with peers.

B. Staff Interview

In an interview on 6/15/10 at 3:30 p.m., RN 5 (a staff member on the patient's treatment unit) was queried regarding the treatment interventions received by sample patient A3 and the availability of translators (signing staff). When the surveyor asked about active treatment provided on the weekends, RN5 stated "We have lots of 'down time' with him [patient A3] on the weekends....we don't have translators on the weekends." When asked if all the unit-based groups that A3 participated in had a translator available so that he could understand what was going on in the group, RN3 stated, "No, we don't."

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

I. Ensure that a neurological examination was recorded at the time of the admission physical examination for 1 of 12 sample patients (A11). The absence of this information prevents the treatment team from addressing patient physical health needs during the course of hospitalization and from developing patient-specific physical health referrals as components of the discharge plan, thus ensuring appropriate attention to the patient's ongoing physical health needs upon re-entry into the community. (Refer to B109)

II. Ensure that that psychiatric evaluations (Comprehensive Psychiatric Exams at admission and annually thereafter) included an inventory of the patients' assets in descriptive, not interpretive fashion for 6 of 12 active sample patients (A2, A4, A5, A7, A8, and A11). The psychiatric evaluations for these patients listed general traits and/or natural/environmental supports as assets, rather than specific attributes possessed by the individual. These failures diminish the ability of the attending psychiatrist to guide the treatment team in recommending and implementing effective treatment interventions based on the personal factors that tend to encourage compliance and capitalize on known strengths. (Refer to B117)

III. Ensure that the Master Treatment Plans (MTPs) were comprehensive (contained all appropriate elements to guide staff in providing optimal treatment) for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A9, A10, A11 and A12).

The facility failed to include: 1) an inventory of patient strengths for 11 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, and A11); 2) a substantiated diagnosis that served as the primary focus for treatment for 1 of 12 active sample patients; 3) individualized short-term goals, described in observable and/or measurable terms, for 12 of 12 active sample patients; 4) specified treatment modalities, with the frequency and duration of all listed interventions, for 12 of 12 active sample patients; and 5) the names of staff responsible for interventions on the Master Treatment Plans (MTPs) for 12 of 12 active sample patients.

Failure to develop Master Treatment Plans that contain all appropriate elements to guide staff in providing treatment (i.e. an inventory of strengths, substantiated diagnoses, individualized and measurable short-term goals, and individualized treatment modalities, the names of responsible staff members) compromises the team's ability to effectively address the patients' problems and to meet the patients' needs for successful and timely return to the community. Refer to B118

IV. Document the provision of intervention modalities as specified in the Master Treatment Plans and modify plans as necessary to provide treatment to patients for 6 of 12 active sample patients (A1, A2, A3, A7, A9 and A11). Many of the interventions listed in the treatment plans were not documented as delivered (in the patient's medical record progress notes). These patients also had low participation levels for interventions that were documented. There was no evidence that alternative activities were developed or offered. Failure to revise and follow the treatment team's plan for active treatment can result in lack of patient improvement and prolonged hospitalizations. (Refer to B125-I)

V. Provide interpreter (sign language) services to assure active treatment for 1 of 12 active sample patients (A3). This patient, hospitalized since 12/09, had a hearing impairment which required interpreter services, and developmental disabilities resulting in inappropriate behavior for which he needed understood oral guidance from staff. These services were not provided on week-ends and were not routinely obtained for the patient's assigned treatment groups. Failure to provide needed translator services for hearing impaired patients results in these patients not obtaining all needed interventions for recovery, potentially prolonging hospitalization. (Refer to B125-II)

Based on record review, observation and interview, it was determined that the Director of Nursing failed to assure that: 1) MTPs of 11 of 12 active sample patients (A1, A2, A3, A5, A6, A7, A8, A9, A10, A11 and A12) specified the names of nursing staff responsible for nursing interventions; 2) all nursing interventions specified on treatment plans of 5 of 12 sample patients (A1, A2, A3, A7, and A11) were documented as delivered, and 3) interpreter services were provided for a hearing impaired sample patient (A3). These failures can result in patients not receiving all needed treatment for recovery, prolonging hospitalization.

Findings include:

I. Failure to assure nursing staff are named on plans

A. Record Review (MTP dates in parentheses)

1. Patient A1 (MTP update 6/9/10). For the problem "Thought/Mood Disorder" the MTP did not list the names of any nursing staff responsible for the following groups: "Unit A [nursing] staff" - "Community Meeting"; "Patient Empowerment for Recovery Group."

2. Patient A2 (MTP update 6/7/10). The MTP was missing the names of any responsible nursing staff for the following intervention related to the problem "Psychotic Disorder": "OT and Nursing Staff" - "Patient Empowerment group." For the patient's communication problem related to "English as a second language," the intervention was "All staff will assess barriers and develop ways to communicate with [patient] to assist in meeting his needs."

3. Patient A3 (MTP update 5/23/10). The MTP failed to identify the names of staff responsible for the following nursing interventions: "TPWs (trained psychiatric worker)" - "Community Meetings"; "LPNs" - "Medication Education group."

4. Patient A5 (MTP update 5/26/10). The MTP failed to list the names of staff for the following nursing interventions: "Nursing" - "Walking for Wellness" group; "TPW staff" - "provide independent living skills training daily."

5. Patient A6 (MTP update 6/2/10). The MTP failed to list the names of any nursing staff for the following interventions: "Unit E [nursing] Staff" - "Patient Empowerment Group"; "Community Meeting"; "Current Events Group"; "Exercise Group"; "Gross Motor Group (exercise)"; "Leisure Exploration Group"; "Modified RAD Group/Promoting Responsible Adult Development Group"; "Workshop Group"; "Unit LPN" - "Medication Education Group"; "Unit RN" - "special precautions for infection control."

6. Patient A7 (MTP update 6/15/10.) The MTP failed to list the names of nursing staff for the following interventions: "Unit LPNs" - "Medication Education group"; "Unit RNs" - "Healthy Issues group."

7. Patient A8 (MTP 6/15/10). The MTP failed to list the names of nursing staff for the following interventions: "Unit RNs" - "RN Healthy Issue group"; "Unit LPNs" - "Med Education group."

8. Patient A9 (MTP update 5/17/10). The MTP failed to list the names of nursing staff for the following interventions: "TPW Staff" - "Community Meeting"; "Current Events"; "Exercise Group"; "Patient Empowerment for Recovery group"; "LPN/RN staff" - "medication Education group"; "RN staff " - "Symptom Management/Health Issues group."

9. Patient A10 (MTP update 6/3/10). The MTP failed to list the names of nursing staff for the following intervention: "LPN" - "Medication Education Group." Several other interventions only listed "All staff" or "Staff" as the responsible persons.

10. Patient A11 (MTP update 5/23/10). The MTP failed to list the names of nursing staff for the following interventions: "Nursing staff" - "Community Meeting"; "Current Events"; "Exercise Group"; "Morning Goal Group"; "Medication Education Group"; "Movie Discussion Group"; "Patient Empowerment for Recovery group." Some additional on-unit activities were assigned to "All staff."

11. Patient A12 (MTP update 5/17/10). The MTP failed to list the specific names of staff responsible for any of the nursing interventions. The plan only said "Unit Nurse"; "Unit J LPN" or "Unit J RN." Some other on-unit activities were just assigned to "Unit J Staff."

B. Staff Interview

In an interview on 6/15/10 at approximately 1:30 p.m., the Director of Nursing acknowledged that the names of staff responsible for many of the listed interventions on the sample patients' treatment plans were missing.

II. Failure to assure that all required nursing interventions are provided

A. Patient A1. A review of progress notes in the medical record from 5/15/10 through 6/14/10 revealed no documentations for the following on-unit nursing groups specified on the treatment plan for the patient: "Community Meeting" and "Patient Empowerment." Weekly summary notes written by the TPW (Trained Psychiatric Worker) for on-unit programming (dated 5/22/10, 5/28/10, 6/3/10 and 6/11/10) stated: "Patient stays by himself...does not attend treatment activities at this time." There was no evidence that alternative interventions were offered to the patient.

B. Patient A2. This patient was a 48 year old Vietnamese male who was admitted to the hospital on 4/16/09 (social work progress note 5/27/10). A nursing progress note written 5/25/10 documented the patient's difficulties communicating with staff and peers, and his lack of active participation in programming. The note stated, "...continues to be difficult to understand when he speaks to staff, is seen as having difficulty in groups with communications issues, and has difficulty with expressing self due to language problems." For the problem "history of assaulting other patients without warning," the MTP (update 6/7/10) listed several group modalities, including on unit community meetings, current events groups, patient empowerment groups, and other nursing groups." The patient was to "show appropriate interaction and boundaries with staff and peers at least 2 x a week for 15 minutes in each group." These group modalities were unrealistic for the patient, given his disabilities and language barriers. There was no evidence of alternative nursing interventions being provided to the patient.

C. Patient A3. Review of the progress notes in the patient's medical record from 5/15/10 through 6/15/10 revealed no documentations for the following nursing interventions specified on the treatment plan: "Community Meetings 30 minutes 2 x per day" and "Medication Education group 30 minutes 2 x per week." This patient was hearing impaired and had difficulty participating in group activities. Yet, there was no documentation of nursing attempts to engage the patient in 1:1 sessions for medication education or to provide alternative activities for the patient.

In an interview on 6/15/10 at 3:30 p.m., RN 5 (a staff member on patient A3's treatment unit) was queried about the patient's treatment and the availability of translators (signing staff) to help the patient with communications. When the surveyor asked about active treatment provided on the weekends, RN5 stated "We have lots of 'down time' with him [patient A3] on the weekends....we don't have translators on the weekends." When asked if all the unit-based groups that A3 participated in had a translator available so that he could understand what was going on in the group, RN3 stated, "No, we don't."

D. Patient A7. A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentations for the following on-unit nursing groups specified on the treatment plan: "LPN: Medication Education"; "RN: Healthy Issues group." Notes by a TPW (5/19/10) and a Social Worker (5/20/10) documented that the patient did not attend scheduled on-unit groups but was going to the Mall for "socialization." There was no evidence that other alternatives were offered to the patient.

Observations of Patient A7 on Unit F on 6/14/10 (11:00-11:30 p.m.) and 6/15/10 (11:00-11:30 a.m.) revealed the patient sitting by himself at a table in the common area. He sat with his head in his hands and was not interacting with staff or other patients. When approached by the surveyor, he declined to be interviewed.

E. Patient A9. A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentation for the following nursing interventions specified on the treatment plan: "Community Meetings (30 minutes 1 x/wk), Current Events (30 minutes 2 x/day), Exercise (30 minutes/day), Patient Empowerment for Recovery"; "Medication Education;" "Symptom Management/Health Issues (2 x/wk)." Weekly TPW summary notes (5/18/10; 5/27/10; 6/5/10) stated that the patient attended groups on and off of the unit. However, there was no documentation regarding the patient's participation in (or response to) these activities or how the activities were helping him achieve his treatment goals.

F. Patient A11. A review of progress notes in the medical record from 5/15/10 thru 6/14/10 revealed no documentation for the following on-unit nursing groups/activities specified on the treatment plan: "Community Meeting, Current Events, Exercise, Med Education, Movie Discussion, Patient Empowerment." A nursing progress note written on 6/8/10 said, "Patient attends few groups on/off unit with little participation." There was no documentation of staff attempts to engage the patient in alternative activities.

In an interview on 6/14/10 at 3:00 p.m., Patient A11 was queried about what the staff was doing for him and his goals for his hospitalization. The patient could not describe any staff interventions that were helpful, nor did he know any of his treatment goals. He said "I've been her almost 10 months but it feels like 10 years." He said he likes "music" but that the music group that he can attend is "just talk, not any instruments."

A treatment team meeting was observed on Unit I on 6/15/10 from 10:50 a.m. to 11:00 a.m. when Patient A11's treatment plan was discussed. The discussion focused on the patient's current behaviors and desire for discharge from the hospital. There was no specific discussion of the patient's lack of participation in the treatment modalities on the MTP or alternative approaches to engage him in treatment.

III. Failure to assure translator services for Patient A3

A. Record Review

1. Problem #2 on Patient A3's Master Treatment Plan (updated 5/23/10) was "[Patient] has a hearing impairment." The long term goal for this problem was "[Patient] will have accommodations for his hearing impairment." The short term goal/objective was "[Patient] will have ways to adequately communicate with staff members and family." The only listed staff intervention was "All staff will communicate with [patient] by writing to him and/or sign language for ongoing management of his hospital treatment and provide continuity for follow-up."

2. A progress note on the 5/23/10 MTP update related to the patient's hearing impairment stated "Pt [patient] meets 1:1 with an interpreter weekly, sometimes for RTC (Restoration to Competency) or psych testing or meet [sic] with a member of his treatment team to discuss his treatment plan. Pt utilizes a writing journal to communicate needs with staff and general conversations."

3. The only progress notes, documenting that an interpreter was immediately available to the patient was a psychologist note (5/19/10) which stated that the patient was informed of the results of psychological testing with an interpreter present and a nursing note (6/10/10) which said the patient "has been receiving 1:1 RTC (Restoration to Competency) sessions with an interpreter to help better communicate information."

B. Staff Interview

In an interview on 6/15/10 at 3:30 p.m., RN 5 (a staff member on patient A3's treatment unit) was queried about the patient's treatment and the availability of translators (signing staff). When the surveyor asked about active treatment provided on the weekends, RN5 stated "We have lots of 'down time' with him [patient A3] on the weekends....we don't have translators on the weekends." When asked if all the unit-based groups that A3 participated in had a translator available so that he could understand what was going on in the group, RN3 stated, "No, we don't."

Based on record review and interview, the facility's Director of Social Work failed to ensure that the social work assessments for 10 of 12 sample patients (A2, A4, A5, A6, A7, A8, A9, A10, A11, and A12) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and from formulating the patient's discharge plan, thereby ensuring seamless re-entry into the community. (Refer to B108)