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Based on record review, observation and interview, the facility failed to ensure that active treatment measures were provided for 6 of 6 active sample patients on Kent 3 (A13, A14, A17, A18, A19 and A20) and 3 of 4 active sample patients on Sussex 1 (B3, B13 and B34). Five of the active sample patients on Kent 3 (A13, A14, A17, A18, A19) who went to the Mall (now called the Recovery Academy) were found to be either attending groups in a random fashion or to be roaming the Mall not engaged in treatment. One sample patient on Kent 3 (patient A20), who did not attend the Mall (Recovery Academy), was observed not receiving active treatment during the survey. The 3 active sample patients on Sussex I were either not motivated to attend the Mall/Recovery Academy, or based on their level of functioning, were deemed unsuitable to attend the mall activities and so remained on the unit and were to receive their treatment there. Observation of patient/staff interactions on the units revealed that the interventions provided failed to relate to the specific problems and needs of the sample patients. Unit groups were open groups that any patient could choose to attend or not attend, and the groups had no individualized focus. Treatment plans for these patients made general statements about encouraging patient to attend modalities on and off the unit and the modalities were listed on the plans by generic topics. In addition, on the units, treatment schedules were not followed. Random observations of the patient population on Sussex 1 (census 34) revealed that no therapeutic activities were occurring, and interviews with staff confirmed this finding. Patients were sitting, wandering, sleeping, or participating in diversion activities such as playing cards. Lack of active treatment results in patients being hospitalized without all needed interventions for recovery being provided to them in a timely manner and potentially delays their improvement. (Refer to B125)

Based on record review and interview, the facility failed to ensure that a Psychosocial Annual Review/update was completed for 1 of 4 active sample patients (B13) on Sussex I unit, and failed to ensure that the Psychosocial Assessments for 2 of 4 active sample patients (B23 and B34), also on Sussex I, provided an evaluation of psychosocial functioning and social work care plan recommendations. The absence of such information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan.

Findings are:

A. Record Review

1. Patient B13. There was no current annual review/update Psychosocial Assessment in the medical record of this patient. The last Annual Psychosocial Assessment was dated 2/9/09.

2. Patient B23. The patient's Psychosocial Assessment Annual review/update, dated 11/30/09, did not include specific information on psychosocial functioning or a social work care plan recommendations other than "Groom the patient to become involved in her physical health needs and learn about her medications"..."Needs support around personal hygiene and how this impacts her ability to be discharged"..."She will be provided with assistance in maintaining regular contact with her family."

3. Patient B34. The patient's Psychosocial Assessment Annual review/update, dated 11/9/09, did not specific information on psychosocial functioning or social work care plan recommendations. The review only stated "Attempts have been made to include her family in treatment planning"..."is cooperative in taking medications on schedule."..."Encourage the patient to become involved in unit activities and eventually help find activities of interest on the Recovery Mall"..."Client increases acts of negative behavior when discharge discussion occurs. Explore with the client why she is anxious about leaving the facility."

B. Staff Interview

In an interview on 2/24/10 at 9:40 a.m., SW #1 agreed with the above findings. She stated that she did not have time to complete the Annual Psychosocial Assessment for B13 or to revise the social assessments for the other patients as needed. "We have been short staffed since the summer of 2009. The Social worker for Sussex I has been on disability since November 2009."

Based on record review and interview, the facility failed to sufficiently document an estimate of intellectual functioning for 10 of 10 active sample patients whose psychiatric evaluations were reviewed (A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34) and memory functioning for 4 of 10 active sample patients (A14, A17, A18 and A20). The testing methods also were not described. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation, and can adversely affect the formulation of treatment goals and interventions. In addition, failure to identify the testing procedures prevents comparative testing to measure patient changes in response to treatment.

Findings are:

A. Record Review (Psychiatric Assessment dates in parentheses)

1. The Psychiatric Assessments for B13 (1/29/10), B34 (1/29/10) and B23 (10/08/09) documented intellectual function with a circle applied to either "below average," "average," or "above average"; B3 (1/29/10) and A14 (2/12/10) had no estimated documentation of intellectual functioning on the assessments; A19 (2/5/10) had the letters "nl" [normal] for the estimation of intellectual functioning; A20 (2/3/10), A18 (2/7/10) and A17 (2/08/10) had the word "average" documenting the estimation of intellectual functioning on the assessments; A13 (2/12/10) had the following estimate of intellectual functioning, "unknown-may be [arrow upward] average." None of the active sample patients' records (A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34) described how the evaluating psychiatrist reached the conclusion through the assessment or interview process.

2. For 4 of 10 active sample patients, (A14, A17, A18 and A20), the facility failed to document memory functioning in the psychiatric assessment.

B. Staff Interview

In an interview on 2/24/10 at 9:10 a.m., the Medical Director and CEO acknowledged that the mental status section of the Psychiatric Assessments reviewed did not have sufficient descriptive commentary in order to substantiate findings for estimation of intellectual findings, and that on 4 of the 10 reviewed records, there was no documentation of memory functioning.

Based on record review and interview, the facility failed to provide a description of patient assets as a component of the psychiatric evaluation for 10 of 10 active sample patients whose psychiatric evaluations were reviewed (A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities which best utilize patient's attributes in therapy.

Findings are:

A. Record Review (Psychiatric Assessment dates in parentheses)

None of the 10 active sample patients' medical records had a section on the psychiatric assessment form to document patient assets, and no inventory of assets was documented on any of the Psychiatric Assessments reviewed; the psychiatric assessments of the 10 active sample patients reviewed were: A13 (2/12/10), A14 (2/12/10), A17 (2/08/10), A18 (2/7/10), A19 (2/5/10), A20 (2/3/10), B3 (1/29/10), B13 (1/29/10), B23 (10/08/09), and B34 (1/29/10).

B. Staff Interview

In an interview on 2/24/2010 at 9:10 a.m., the Medical Director and the CEO (Chief Executive Officer) acknowledged that there was no section on the active sample patients' Psychiatric Assessments for an inventory of patient assets, and that no inventory of patient assets were included on the Psychiatric Assessments for patients A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34.

Based on record review and interview, the facility failed to develop Master Treatment Plans that identified interventions to address specific patient problems for 4 of 4 active sample patients on Sussex I unit (B3, B13, B23 and B34). Many of the interventions were routine generic functions expected of each discipline. This failure results in a lack of guidance for staff to provide individualized patient treatment that is purposeful and goal-directed.

Findings are:

A. Record Review

1. Facility policy, Number TX 26, titled "Function Care of Patients" revised draft dated 2/3/10, states "All person centered recovery oriented activities and/or support services will be directly related to the goals"..."and also be written as interventions."..."Intervention/strategies will specify the approach that will be used to assist the individuals in reaching their goals."

2. Active sample patient B3.

The Master Treatment Plan, updated 11/30/09, listed the following generic discipline interventions: Physician: "Monitor mental status and made [sic] adjustments as necessary." Nursing: "Administer medications as prescribed. Provide reassurance during medication administration." Social Work: "Community meetings for 15 minutes 5x [five times] per week for 60 days to promote social interactions with others." Psychology Staff: "Individual therapeutic contact for 15 minutes 2x per month for 30 days to provide support/reassurance, monitor status, promote reality, build trust, and encourage communication."

3. Active sample patient B13.

The Master Treatment Plan, updated 1/26/10, listed the following generic discipline interventions: Physician: "Antipsychotic medications as prescribed to reduce psychotic symptoms." Nursing: "Administer medications as ordered"..."Provide reassurance during medication administration and report to the treatment team when client voices ambivalence." Social Work: "Community meeting for 15 minutes 5x week for 30 days to promote appropriate social interactions with others." Psychology: "Individual therapeutic contact for 15 minutes 2x month for 30 days to provide support, develop a trusting relationship, provide client with an opportunity to express her feelings."

4. Active sample patient B23.

The Master Treatment plan, updated 10/21/09, listed the following generic discipline interventions: Physician: "Antipsychotic medications as prescribed to decrease psychotic symptoms." Nursing: "Administer medications as ordered." Social Work: "Community meeting for 15 minutes 5x per week for 90 days to promote appropriate social interventions with others"... "Individual therapeutic contact for 15 minutes 2x month to provide support, promote reality. Teach coping strategies, and provide pt [patient] with an opportunity to express her feelings."

5. Active sample patient B34.

The Master Treatment Plan, updated 10/05/09, listed the following generic discipline interventions: Physician: "Antipsychotic medications as prescribed to decrease psychosis." Nursing: "Administer medications as ordered." Social Work: "Community meeting for 15 minutes 5x per week for 90 days to promote appropriate social interactions with others." Psychology: "Individual therapeutic contact for 15 minutes 2x month for 90 days to provide support, encourage interaction, assess reality orientation and provide client with an opportunity to express her feelings."

B. Staff Interviews

1. In an interview on 2/22/10 at 4:30 p.m. with the Deputy CEO (Chief Executive Director) on generic interventions on the Master Treatment plans, she stated that education and training on Sussex I on the revised treatment plan policy and procedures had not been implemented yet so the quality of the treatment plans would not reflect improvement.

2. In an interview on 2/23/10 at 12:00 p.m., the Director of Professional Services (a Mastered prepared nurse who was responsible for treatment plan training) stated that she was still working on treatment plan improvement on Kent

3. She admitted that education and training of the disciplines on Sussex I would not be started for some time because she expected that her work with staff on Kent 3 would not be completed for at least another month.

Based on record review, observation and interview, the facility failed to ensure that active treatment measures were provided for 6 of 6 active sample patients on Kent 3 (A13, A14, A17, A18, A19 and A20) and 3 of 4 active sample patients on Sussex 1 (B3, B13 and B34). Five active sample patients on Kent 3 (A13, A14, A17, A18 and A19) went to the Mall (now called the Recovery Academy) but were found to be either attending groups in a random fashion or roaming the Mall rather than being engaged in treatment. Kent 3 sample patient A20 who did not attend the Mall (Recovery Academy), was not observed receiving active treatment any time during the survey. The 3 active sample patients on Sussex I were either not motivated to attend the Mall/Recovery Academy, or because of their level of functioning, were deemed unsuitable to attend the Mall activities. They remained on the unit and were to receive their treatment there. Observations of patient/staff interactions on the units revealed that the interventions provided failed to relate to the specific problems and needs of the sample patients. Unit groups were open groups that any patient could choose to attend or not, and the groups had no individualized focus. On the units, treatment schedules were not followed. Random observations of the patient population on Sussex 1 (census 34) revealed that no therapeutic activities were occurring, and interviews with staff confirmed this finding. Patients were sitting, wandering, sleeping, or only doing activities for diversion such as playing cards. The lack of active treatment results in patients being hospitalized without all needed interventions for recovery being provided to them in a timely manner, potentially delaying their improvement.

Findings are:

A. Specific patient findings

1. Active sample patients A13, A14, A17, A18, A19 and A20 on Kent 3 unit

a. Patient A13

1) According to the Psychiatric Evaluation dated 2/12/10, patient A13 was admitted on 2/12/10 with a diagnosis of "Mood disorder, NOS [not otherwise specified], cannot r/o [rule out] psychosis"..."appeared possibly psychotic, may have dementia. Multiple medical co- morbidities"..."Possible organic brain dysfunction 2nd to ESRD [secondary to end stage renal disease]." The patient was "receiving hemodialysis three times a week (Mondays - Wednesdays - Fridays)"..."Pt [patient] feeling depressed that he may have Alzheimer's which father had."

2) According to facility policy, the Master Treatment Plan (MTP) of A13 was not due to be developed until 2/26/10 (ten work days from date of admission). This was 14 days after the patient had been admitted to the facility. The "Initial Treatment Plan," dated 2/12/10 (only available plan at time of survey) listed "Group/individual therapy, HD [hemodialysis] 3x [3 times]/week" as physician interventions. There were no other discipline interventions listed on the Initial Treatment plan.

3) In an interview with patient A13 on 2/23/10 at 8:50 a.m., he stated that he had a copy of his Recovery Academy schedule but that he had only been to the Academy once before. When asked what he did there, he said he just sat around and did nothing. When asked if he had been assigned to any groups in a treatment team meeting, A13 stated "No. A social worker sat down with me last week and helped me pick out some groups. I have not followed this schedule as yet."

4) The patient's Recovery Academy (formally called Recovery Mall) schedule listed groups only on Tuesdays and Thursdays as the patient received hemodialysis the other 3 week days. For 2/23/10, A13's schedule showed that he was to attend the "Coping Skills" group at 9:15 a.m. and "Living a healthy life" group at 10:10 a.m. that morning.

5) A13 was observed going to the Academy on 2/23/10 at 9:20 a.m. with 14 other patients from Kent 3. The group was accompanied by two psychiatric aides (PA's). The 15 patients attempted to line up in a row at the desk where Academy staff had a list of patient assignments for the various scheduled groups. However, the Academy secretary told the group that they did not need to report to the desk. "We know you are here and have already checked you in." Patient A13 showed the secretary his schedule and was directed to Room 44 for the "Coping Skills" group which was scheduled to start at 9:15 a.m. The group started at 9:30 a.m. and lasted for 15 minutes. Six patients, including A13 and another active sample patient (A17), were in attendance. RT #A, the group leader, did not know the names of the two active sample patients.

6) In an interview on 2/23/10 at 9:45 a.m. after the Coping Skills group described above, RT #A was asked how she was going to chart on active sample patients A13 and A17. She stated that she would not chart on them because neither patent was on her list as being assigned to this particular group. The list she had included the names of patients and each patient's goal/objective for being assigned to the group. Because patients A13 and A17 were not on RT #A's list, the group leader did not know the goals for these two patients.

b. Patient A14

1) According to the Psychiatric Evaluation dated 2/12/10, patient A14 was admitted on 2/12/10 with a diagnosis of "chronic paranoid schizophrenia, r/o schizoaffective d/o [disorder)." The evaluation said "Pt was on the streets and found to be hypothermic at a bus stop"..."body temp was 77°"..."second admission for hypothermia"..."chronic and severe mental illness [which] hasn't been controlled by med [medication], partly due to [no] adherence [sic]." The evaluation stated that the patient denied walking outside without a coat even though she was found unconscious, and that she was having seizures when admitted to a hospital. The evaluation also said that the patient has had multiple previous admissions to Delaware Psychiatric Center

2) According to facility policy, the Master Treatment Plan for A14 was not due to be developed until 2/26/10 (ten work days from the date of admission). This was actually 14 days after patient's admission. The "Initial Treatment Plan," dated 2/11/10 [sic] and available at time of the survey, listed the following interventions: Social Work (on housing): "Will discuss possible options." No discipline listed: "psychotropic meds." Nursing: "Monitor lithium levels, monitor medication administration, encourage group participation." No Treatment Academy groups were listed on the Initial Treatment plan. Because of the delay in developing the MTP, staff only had the limited Initial Treatment Plan to work with the patient for 14 days.

3) In an interview on 2/22/10 at 12:40 p.m., patient A14 stated that she went to the Academy, but just sat around after she got there. "We are not kept busy."

4) The Recovery Academy schedule for A14 listed the following groups for Monday 2/22/10: "Wellness" group (9:15 a.m.), "Art for fun" (10:10 a.m.), "Music Appreciation" (1:15 p.m.), and "A new you" group (2:10 p.m.). None of these groups were on the patient's treatment plan. The patient was observed in the Recovery Academy on 2/22/10 attending the "Current events" group at 1:15 p.m. instead of the assigned "Music Appreciation" group. She attended her scheduled "A new you" group at 2:20 p.m. on 2/22/10, but her name was not on the Academy's list of patients assigned to that group. Therefore, the group leader did not know the patient or her goal for attending the group. The patient's name also was not listed on the Academy schedule for the 2 morning groups, which were on her individual schedule.

5) In an interview on 2/22/10 around 2:30 p.m., OT #A was asked about the absence of Kent 3 patients' name on the group schedule in the Recovery Academy. She stated that the Kent 3 patients' individual schedules are either faxed over or hand-carried to the Treatment Mall, but that they often get put in a stack of papers on a desk without anyone adding the names to the master list of scheduled groups, or that they might get lost.

6) In an interview with the Assistant CEO (Chief Elective Officer), Recovery Academy's Director and the Director of Professional Services on 2/23/10 at 12:00 p.m., the problem of Kent 3 patients being assigned to the Recovery Academy without the Academy staff's inclusion of them on their group lists was discussed. The interviewed staff acknowledged the problem and said it was due to a lack of specific staff being assigned for scheduling of patients to the various groups offered in the Mall.

c. Patient A17

1) According to the Psychiatric Evaluation dated 2/8/10, patient A17 was admitted on 2/8/10 with a diagnosis of "schizophrenia, paranoid type, and antisocial personality traits." The evaluation said "Pt stated he came to the hospital for stomach problems"... "He is not eating or drinking." "He appeared guarded, suspicious with poor attention. He reported auditory hallucinations"..."He sometimes feels that people are trying to harm him"..."Client has genetic vulnerability to mental illness as his mother has mental illness"... "Physical abuse in childhood aid relationship stressors."

2) The Master Treatment Plan for A17 was dated 2/22/10. This was ten work days from admission, but 14 actual days after patient had been admitted to the facility. The MTP listed the following Recovery Academy groups: "Relaxation, Movement and Socialization, Cycling, Coping Skills, Stress Management, Be More Flexible, and Group Therapy." These same groups were circled on the patient's individual Recovery Academy schedule and were appropriate for the treatment plan goals. However, observations on 2/22/10 in the Recovery Academy revealed that the patient attended "Current events" group at 1:15 p.m. instead of his assigned "Be more flexible" group, and a "A new you" group at 2:10 p.m. instead of the assigned "Coping skills" group. The Recovery Academy's patient assignment list did not include A17's name in either of the two groups he attended on 2/22/10. The two attended groups also were not on his MTP.

3) In an interview on 2/22/10 around 1:30 p.m., Psychiatric Aide PA #A was asked why patient A17 was in his "Current Events" group when the patient's schedule stated that he should be in the "Be More Flexible" group. PA #A stated that the Kent 3 patients were not yet included in the Recovery Academy's patient assignment list, so that these patients were free to attend any group they wanted.

4) Patient A17 was accompanied by Kent 3 unit staff to the Recovery Academy on 2/23/10 at 9:20 a.m. He stopped at the assignment desk, but was told by the Recovery Academy's secretary "You are already checked in; just go on down that hallway." The secretary was pointing to the hallway on the far right of the room. Patient A17 went into Room 44, one of several group rooms along the hallway on the right. The group held in Room 44 from 9:30 a.m. to 9:45 a.m. was "Coping skills." The patient's individual schedule stated that he was to attend "Leisure Recreation" at 9:15 a.m.

d. Patient A18

1) According to the Psychiatric Evaluation dated 2/07/10, Patient A18 had an Axis I diagnosis of "Schizophrenia, Chronic Paranoid Type and the current GAF score was listed as "30." The evaluation identified "circumstantial thinking" as her most disabling psychiatric symptom. Significant psychosocial factors contributing to her need for psychiatric hospitalization included the following: "ongoing conflicts with her son's girlfriend, unemployment, homeless, mental illness since 1994."

2) The Master Treatment Plan for A18, dated 2/19/10, listed the following interventions for the Recovery Mall: "Coping Skills, Meditation, and Relaxation Groups to help [Patient A18] learn methods of coping with the stress of a new living environment and her family dynamics regarding her children"; "Staying Sharp and Creative Minds Groups to help [patient] 'use her mind' and to help her gauge her concentration level"; "Self-Esteem Group to help [patient] view herself and her future in a positive way"; "Current Events Group to help [patient] remain in touch with the happenings in the community"); "My Spare Time to provide [patient] methods of occupying her time when she is discharged." Patient A18 did not attend these groups when observed on 2/22/10. Specific observations and interviews are listed below. Active treatment was not provided.

3) On 2/22/10 at 1:20 p.m., Patient A18 was observed roaming the hallway of the Recovery Academy/Mall area. Her Recovery Mall schedule showed that she was to attend the "Current Events" group. The patient did not receive active treatment during the observation.

4) On 2/22/10 at 1:20 p.m. on the Recovery Academy/Mall, Patient A18 was observed attending the "Current Event" group. The group took place in a large dayroom and had 16 patients and one therapist. It was difficult to hear the therapist's comments at the opposite end of the room. The group was chaotic and non-therapeutic for Patient A18.

5) In an interview on 2/22/20 at 1:20 p.m. patient A18 stated "I don't know where I am suppose to be...they told me I can go to any group...I want my medication changed...it is too strong...who do I talk to about this...where do I go?"

6) In an interview on 2/22/10 at 2:00 p.m., PA # A, the group leader of the "Current Events" group noted in item "c" above, reported that he was not aware that Patient A18 was assigned to his group. He also stated that he was not familiar with this patient's needs or treatment goals.

7) The observations and interviews above document the random nature of the Recovery Academy/Mall activities for patient A18. The patient did not participate in an activity designed to help her meet her treatment goals. Staff did not make attempts to assure that the patient attended activities based on her needs.

e. Patient A19

1) According to the Psychiatric Evaluation dated 2/05/10, Patient A19 had Axis I diagnoses of "Mood d/o NOS-bipolar vs. substance induced, ETOH dependency, Dementia [secondary to] hepatic failure [hepatic encephalopathy]." The GAF score was listed as "30." Patient A19 had been transferred from the local medical hospital following his treatment there for hepatic encephalopathy, in order to get a psychiatric evaluation and treatment for ongoing cognitive deficits, such as memory loss, as well as for co-occurring chemical dependency.

2) The Master Treatment Plan for A19, dated 2/19/10, listed the following interventions for the Recovery Mall: "Recovery Mall Groups: Co-Occurring Disorder, Creating Pathways to Recovery, and Co-Occurring Art Therapy to encourage [Patient A19] to increase his motivation for Recovery." Patient A19 did not attend these groups when observed on 2/23/10. When observed on 2/22/10, he was in an unassigned group. He attended groups in a haphazard fashion and not as scheduled. Specific observations and interviews are listed below. Active treatment was not provided.

3) At 1:25 p.m., on 2/22/10 while walking to the 'Creative Pathways' group, Patient A19 reported "I went to that room and there was no one there...so someone told me to go to the "Current Events" group until the group got started...I thought it was not going to happen." The Art Therapist at this time stated "I had no idea he [Patient A19] was assigned to my group...he must be from Kent 3...I don't know him."

4) On 2/23/10 at 10:00 a.m., Patient A19 was observed roaming the hallway of the Recovery Mall. In an interview at this time, the patient was asked what group he was to attend. He responded, "I don't know."

5) On 2/23/10 at 10:00 a.m. the Recovery Mall secretary became aware that Patient A19 was not in a group, and that the patient was talking with a surveyor. When the secretary could not locate patient A19's schedule in the notebook containing patient schedules, she directed the patient to a board that listed all of the Mall activities. She said to Patient A19 "I can't find your schedule...look at these groups [pointing to the board]...which one would you like?" The secretary then said "Why don't you go to 'Living a Healthier Life'...It is pretty good...I think you would like it." Patient A19 agreed to go to that group. When asked why he agreed, he responded "It is the group where you draw things and talk about your life." He clearly thought he was attending the same group he had attended the previous day with the Art Therapist. These observations and interviews documented the random nature of the mall activities for this patient. This patient did not participate in an activity that met his individual treatment needs or goals. Staff did not assure that the patient attended activities chosen by the treatment team for the patient.

f. Patient A20

1) According to the Psychiatric Evaluation dated 2/03/10, Patient A20 had Axis I diagnoses of "Major Depressive disorder with Psychotic features, Eating d/o NOS, PTSD," and an Axis II diagnosis of "Cluster B Traits." Her admission GAF score was listed as "40." She had been admitted following a serious suicide attempt by overdose of aspirin. Additionally, Patient A20 had multiple identified psychiatric symptoms which included "not eating"; "depression"; "suicidal ideas" and "relationship difficulties-- not getting along with her supported housing roommate."

2) The Master Treatment Plan for A20, dated 2/18/10, listed the following interventions for the Recovery Mall: "Recovery Mall Groups to help her learn coping skills and build self-confidence: Self-Esteem/Social Skills, Coping Skills, Anger Management, Coping with Stress, Relaxation, Self Esteem, Self determination and Stress Management Group...Dealing with Trauma Through Art Therapy to give her an outlet to express her feelings about her trauma which may help [repress] the hallucinations and recurrent thoughts." Patient A20 did not attend any groups at the Mall when observed on 2/22/10 and 2/23/10. Specific observations and interviews are listed below. Active treatment was not provided.

3) In interviews on 2/22/10 at 11:30 a.m., 1:30 p.m. and 2:30 p.m., patient A20 stated "I have refused to go to the Mall...there are too many people there...I have not been to the Mall since I've been here. I'm not comfortable with others...get anxious...the setting is too chaotic for me...I had no groups this morning...I am suppose to have a 1:1 with [RT-3] at 1:30 p.m. or 3:30 p.m. today."

4) Patient A20 was observed on 2/22/10 at 11:30 a.m., 1:30 p.m. and 2:30 p.m. on unit Kent 3 playing cards with another patient in the day room. She reported this had been her only activity throughout the day. This was not active treatment.

5) On 2/22/2010 at 2:30 p.m. Patient A20 was observed On Kent 3, playing cards with another patient and RT #3. The RT #3 stated "this is our 1:1 for the day."

6) Patient A20's Recovery Mall schedule had multiple groups circled, indicating chosen groups for her. The form had the statement "Client Refused" written across the front of the form. There were no alternative activities listed.

7) In an interview at 1:45 p.m. on Kent 3, Physician 1 reported that Patient A20 does not attend the Recovery Mall but that she stays on the unit.

8) In an interview on 2/23/10, at 9:18 a.m., Patient A20 stated that she would have the same activities as she had on 2/22/10. This would include remaining on the unit and not attending the Mall and would have a 1:1 with RT-3. The 1:1 with RT-3 was described as recreational, like playing cards. She again stated, "I refuse to go to the Mall...I am not sure what time my 1:1 will be today." This was not goal directed active treatment.
2. Active sample patients B3, B13, and B34 on Sussex I unit

a. The Sussex I on-unit groups were comprised of open groups that any patient could attend (confirmed by RN #A in an interview on 2/23/10 at 1:20 p.m.). These groups were held on A and B pods, and they had no individual patient focus. Patients who were unwilling or unable (due to cognitive impairment) to attend groups on A or B pods spent their day on C Pod. A unit schedule was provided for groups held on A or B pods, but none was available for C pod. Active sample patient B13 was scheduled to attend the Recovery Academy, but refused to go. Active sample patients B3 and B34 were assigned to the C pod unit where, according to PA 3A, there was only one group held daily at no specific time... "just in the morning." Treatment plans for the 3 active sample patients (B3, B13, and B34) listed generic groups on the unit. These groups were "Community Meeting, "Current Events" and "Evening Express."

b. Specific Patient Findings

1) Patient B3

a) According to the Annual Psychiatric Evaluation dated 1/29/10, patient B3 was admitted on 9/25/09 with a diagnosis of "dementia, NOS [not otherwise specified]." "Client is at his baseline...waiting for placement to dementia unit."

b) The Master Treatment Plan review for B3 dated 1/29/10 included the following: For "Group Activities," the review stated "[Name of patient] participated in some group activities on the unit, primarily on C POD. He spent a majority of his time in that location. He occasionally participates in the TLA [sic] talk group and also participated with OT [occupational therapy] staff during C POD 1:1 times. He continues to be pleasantly confused and requires frequent redirection."

c) A Psychologist's Monthly Progress note, dated 1/26/10 at 4:25 p.m. stated "He enjoys spending time on C POD and occasionally attends a few unit grp [groups]/activities."

d) A Monthly Nursing note, dated 1/23/10 at 2:10 a.m. stated the following: "[Name of patient] usually stays in C POD day hall. He will attend unit activities there, but not attend Recovery Mall."

e) In an interview on 2/23/10 around 1:10 p.m., RN #A stated that patient B3 attended the Recovery Academy the first few days after his admission but hasn't been there since that time.

f) In an interview on 2/23/10 at 1:35 p.m., PA #B was asked if patient B3 attended groups on C POD. PA #B stated that patient B3 was assigned to C POD so was present when any groups were held there, but stated "he's very confused. He is not always aware of what's going on and seems to have difficulty following conversation." When asked about an activity schedule for C POD, PA #B stated that there wasn't one. She stated that a RT [recreation therapist] was assigned to do groups on C POD daily, but ward staff don't know exactly when someone [staff] was coming. "They just show up." She also stated that the RT group was held sometime during the morning hours. "There are no groups on C POD in the afternoon."

g) On 2/23/10 around 2:40 p.m. PA #C was asked what groups were held for patients on C POD. PA #C answered "What groups?"

h) Patient B3 was observed in a group held on B POD of Sussex I on 2/22/10 at 2:30 p.m. RT #2 was the group leader. The name of the group was "Creative Moments." This group was not listed in the patient's Master Treatment Plan, dated 11/30/09. Patient B3 was instructed by the group leader to draw pictures from one sheet onto another, but was unable to do so.

i) On 2/22/10 around 2:40 p.m., RT #2 was asked about any other groups patient B3 had attended for the day. RT #2 stated that the patient had attended a "Current Events/Reality Orientation" group from 9:30 a.m. to 11:00 a.m. on C POD of Sussex I. "He was present, but not able to participate." RT #2 stated that the morning "Current Events" group was the first group that B3 had attended with her in the past two weeks.

j) The C POD group attendance sheet for B3 for the period of 2/15/10 to 2/19/10 was reviewed. There was only one group listed as being held per day. The attendance sheet for B3 documented the following groups:
2/15/10 - no groups listed.
2/16/10 - "Bodies in Motion" at 9:40 a.m. for 10 minutes - no comments
2/17/10 - "Bodies in Motion" at 9:40 a.m. for 10 minutes- "participation"
2/18/10 - No group sheet found.
2/19/10 - "Brain training" at 1:40 p.m. for 40 minutes

2) Patient B13

a) According to the Psychiatric Evaluation dated 1/29/10, Patient B13 had Axis I diagnoses of "Schizoaffective d/o, bipolar type, Impulsive Control d/o [disorder]." The GAF [Global Assessment of Functioning] score was listed as "35." The patient was described as "unkempt, uncooperative, agitated" and had "refused" to respond to mental status examination questions on thought content, thought process, orientation, and memory. In the sections of the evaluation describing hospital course for the previous year and "Factors Necessitating Continued Hospitalization," the physician wrote the following: "Client sometimes is compliant and sometime refuses her meds. When she is refusing client is not stable. Now client is in non-refusal status and gets IM [intramuscular] upon refusal"..."Needs to be stabilized."

b) The Master Treatment Plan for B13, dated 1/26/10, listed the following groups for the Recovery Mall: "Recovery Mall Groups M-F at least 10x per week x 45 minutes each session for 30 days to: allow staff to monitor psychotic symptoms and agitation, provide evidence that psychotic symptoms and agitation are not interfering with activities." These groups were not goal-directed activities for the patient, but were for staff monitoring needs. The patient did not attend these groups in the Recovery Mall. The listed intervention for Activity Therapy was: "Music Group for 30 minutes 1x per week for 30 days to increase appropriate social interaction and self expression." There was no 1:1 intervention for Activity Therapy.

c) In an interview on 2/23/10 at 1:20 p.m., RN #A (the RN Manager on Sussex 1) reported that the facility's new treatment planning process was not in place at that time.

d) The treatment schedule for Patient B13 had a note attached which read "Did not agree to sign up at this point but will most likely change her mind. We don't want her to be put in leisure when she goes down to the Mall." When queried about this, RN#A acknowledged that active sample patient B13 did not attend activities in the Mall. She reported that OT [occupational therapy], RT [recreational therapy] and the Art Therapist come to the ward to provide generalized or recreational activities only. She stated "Patients mainly stay in the Pods and have recreational activities."

e) Patient B13 was observed attending the art therapy group on 2/23/10 at 1:30 p.m. on the Sussex 1 unit (B Pod). The patient colored a picture throughout the session. The Art Therapist was interviewed following the group and asked how patients were selected to participate in the group. He stated, "I go through the unit and find patients who might benefit from the group." He described a process that did not use treatment team input or selection based on individual patient needs or goals. The Art Therapist gave the surveyor a written description of the group which noted generic cognitive skill development as the purpose of the group.

3) Patient B34

a) According to the Psychiatric Evaluation dated 1/29/10, Patient B34 had an Axis I diagnosis of "Schizophrenia, disorganized type." The GAF score was listed as "35." The patient was described as "unkempt, uncooperative, calm, agitated [sic]" and had "refused" to respond to mental status examination questions on thought content, thought process, orientation, and memory. In the sections of the evaluation describing hospital course for the previous year and "Factors Necessitating Continued Hospitalization," the physician wrote the following: "Poor progress, limited understanding of her surroundings...Unpredictable behavior."

b) The Master Treatment Plan, dated 10/5/09, listed the following interventions: Activity Therapy - "C Pod story time for 15-30 minutes 2x per week for 90 days to increase appropriate social skills, increase attention, provide evidence that agitation and psychosis are not interfering with activities, and encourage Client to recognize other enjoyable activities as well as alternatives that can be utilized to handle stress." Social Work - "Community Meeting for 15 minutes 5x per week for 90 days to promote appropriate social interactions with others." Psychology - "Individual Therapeutic Contact for 15 minutes 2x per month for 90 days to provide support, encourage interactions, assess reality orientation, and provide Client with an opportunity to express her feelings." There were no other structured activities on the treatment plan.

c) In an interview on 2/23/10 at 1:20 p.m., RN #A (the RN Manager on Sussex 1) reported that the facility's new treatment planning process information had been shared with the unit staff but that the process was not in place at that time. RN #A acknowledged that patient B34 did not attend activities on the Mall. She stated; "Patients mainly stay in the Pods and have recreational activities." There was no schedule of individualized activities provided for Patient B34.

d) At 1:35 p.m., on 2/23/10 on Sussex 1, Patient B34 was observed sleeping on a sofa in Pod C. There were eight other patients also sleeping or watching TV. According to RN #A, "this was their scheduled activity for the afternoon." There was no written schedule for C Pod. During the observation, there was no evidence of active treatment.

B. Staff Interview

In an interview on 2/23/2010 at 12:15 p.m., the Director of the Mall/Recovery Academy, the Assistant CEO (Chief Executive Officer), and the Acting Director of Professional Services acknowledged that the facility had only progressed to piloting the drafted policy entitled "PERSON CENTERED RECOVERY PLANNING & IMPLEMENTATION." The new policy, dated February 3, 2010 (Revised Draft), had been implemented on unit Kent 3 around the second week in January 2010. The interviewed staff reported that the policy had been disseminated throughout the facility; however no changes in provision of patient care were expected on Sussex I because there had been no specific training on that unit. The Acting Director of Professional Services, Assistant CEO and the Director of the Mall/ Recovery Academy also acknowledged that the Mall/Recovery Academy process failed to ensure that Kent 3 patients participated in scheduled program activities listed on their individual activity sheets. They acknowledged that the disconnect between the groups listed on the individual patient schedules and the groups actually attended in the Recovery Academy resulted in lack of active treatment for sample patients A13, A14, A17 A18, A19 and A20 on Kent 3. The Acting Director of Professional Services, the Assistant CEO, and the Director of the Mall/ Recovery Academy also reported that there was a "void or lack of active treatment" for other patients who were not able to attend the Mall/Recovery Academy, such as patients on unit Sussex 1.

Based on record review and interview, the facility failed to provide adequate Social Work staff to assure that Psychosocial Annual Review/Updates were provided for 1 of 4 active sample patients (B13) on ward Sussex 1, and failed to ensure that the updated Psychosocial Assessments for 2 of 4 active sample patient (B23 and B34) also on ward Sussex 1, provided an evaluation of psychosocial functioning and social work plan of care recommendations. This failure hampers the treatment team's ability to address critical patient needs during the course of hospitalization and formulate the patient's discharge plan.

Findings are:

A. Record Review (Psychosocial Assessment dates in parentheses)

1. In active sample patient B13's record, the most recent Psychosocial Assessment Annual Review/Update was 2/09/09. The 2010 Annual Psychosocial Assessment was not in the medical record at the time of the survey (2/22/10-2/24/10).

2. The Annual Psychosocial Assessments for active sample patients B23 (11/30/09) and B34 (11/9/09) did not provide evaluations of psychosocial functioning or social work plan of care recommendations.

B. Staff Interview

In a joint interview on 2/24/10 at 9:40 a.m., the Director of Psychiatric Social Work, the Social Worker assigned to wards Sussex 1 and 3, and the CEO confirmed that the social work department for the facility was "short staffed." The one assigned social worker for Sussex 3 had been deployed to Sussex 1 to provide additional social work services for that unit since November 2009. This social worker for wards Sussex 1 and 3 stated "I didn't have time to complete the annual evaluation for [the Sussex 1 patient B13]...it is on my computer." The Director of Psychiatric Social Work stated "We have been short staffed since the summer of 2009 because of a state hiring freeze, the loss of social workers due to one retirement, two resignations...two social workers are out due to long-term disability...the social worker for Sussex 1 has been on disability since about November 09" The Director of Psychiatric Social Work acknowledged that providing social services to the inpatient units was a "challenge."

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

I. Ensure that an estimate of intellectual functioning was documented for 10 of the 10 active sample patients whose psychiatric evaluations were reviewed (A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34). On 4 of 10 active sample records reviewed (A14, A17, A18 and A20), the Medical Director failed to ensure documentation of memory functioning. The methods used for testing also were not described. Lack of this basic clinical information can negatively affect decision-making on the need for further evaluation, and can adversely affect the formulation of treatment goals and interventions. Failure to identify the testing procedures prevents comparative testing to measure patient changes in response to treatment. (Refer to B116.)
II. Ensure that a description of patient assets was included in the psychiatric evaluation for 10 of 10 active sample patients (A13, A14, A17, A18, A19, A20, B3, B13, B23 and B34). The failure to identify patient assets impaired the treatment team's ability to choose treatment modalities which best utilized the patient's attributes in therapy. (Refer to B117.)

III. Ensure that Master Treatment Plans identified interventions to address specific patient problems for 4 of 4 active sample patients on Sussex I unit (B3, B13, B23 and B34). Many of the interventions were routine generic functions expected of each discipline. This failure results in a lack of guidance for staff in providing individualized patient treatment that was purposeful and goal-directed. (Refer to B122.)

IV. Ensure that active treatment measures were provided for 6 of 6 active sample patients on Kent 3 (A13, A14, A17, A18, A19 and A20) and 3 of 4 active sample patients on Sussex 1 (B3, B13 and B34). Five of the active sample patients on Kent 3(A13, A14, A17, A18 and A19) went to the Treatment Mall (now called the Recovery Academy) but were found to be either attending groups in a random fashion or to be roaming the Mall not engaged in treatment. Active sample patient A20 from Kent 3 did not attend the Mall (Recovery Academy) and was never observed receiving active treatment during the survey. The 3 active sample patients on Sussex 1 (B3, B13 and B34) either were not motivated to attend the Mall/Recovery Academy, or based on their level of functioning, were deemed unsuitable by the treatment team to attend the mall activities and so remained on the unit and did not receive adequate treatment. Observation of patient/staff interactions on the units revealed that the interventions provided failed to relate to the specific problems and needs of the sample patients. Unit groups were open groups that any patient could choose to attend or not, and the groups had no individualized focus. On the units, unit schedules were not followed. Random observation of the patient population on Sussex 1 (census 34) revealed that no therapeutic activities were occurring, and interviews with staff confirmed this finding. Patients were observed sitting, wandering, sleeping, or participating in diversion activities such as playing cards. The lack of active treatment results in patients being hospitalized without all needed interventions for recovery being provided to them in a timely manner, potentially delaying their improvement. (Refer to B125)

In an interview with the Medical Director on 2/24/10 at 9:10am, the above problems were discussed. He did not dispute the findings.

Based on record review and interview, the Nursing Director failed to ensure that the Master Treatment Plans of 4 of 4 active sample patients (B3, B13, B23 and B36) consistently identified nursing interventions to address specific patient problems. Most of the listed nursing interventions were routine generic functions expected for nurses on psychiatric units, not individualized interventions based on the patients' assessed needs. Failure to document specific nursing interventions on patients' Master Treatment Plans hampers staff's ability to coordinate care and provide consistent approaches for each patient's problem(s).

Findings are:

A. Record Review

1. Active sample patient B3. The Master Treatment plan, updated 11/30/09, listed the following generic nursing intervention: "Administer medications as prescribed. Provide reassurance during medication administration."

2. Active sample patient B13. The Master Treatment plan, updated 1/26/10, listed the following generic nursing interventions: "Administer medications as ordered"; "Provide reassurance during medication administration and report to the treatment team when client voices ambivalence."

3. Active sample patient B23. The Master Treatment plan, last updated 10/21/09, listed the following generic nursing intervention: "Administer medications as ordered."

4. Active sample patient B34. The Master Treatment plan, last updated 10/05/09, listed the following generic nursing intervention: "Administer medications as ordered."

B. Staff Interview

In an interview on 2/23/10 at 12:00 p.m., the Acting Director of Professional Services (a Master's level registered nurse) agreed with the above findings for the Sussex I patients. She stated that treatment plan training for staff on that unit had not yet been scheduled.

Based on record review and interview, the Social Work Director failed to ensure that a Psychosocial Annual review/update was completed for 1 of 4 active sample patients (B13) on Sussex I unit and failed to ensure that the Psychosocial Assessments for 2 of 4 active sample patients (B23 and B34) provided an evaluation of psychosocial functioning and social work care plan recommendations. The absence of such information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan. (Refer to B108)

In an interview with the Social Work Director on 2/24/10 at 9:40 a.m., the above problems with the Psychosocial Assessments and Annual review/updates were discussed. The Social Work Director agreed with the findings.