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Based on record review, observation, and interview the facility failed to ensure that active treatment measures, such as group and/or individual treatment, were provided for one sample patient (A6) and one patient (A9) added to the sample in order to evaluate active treatment. Specifically, Patients A6 and A9 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on medical record review and interview, the facility failed to provide a complete physical and neurological examination for one of nine patients selected (Patient A9). The Psychiatric Evaluation, dated 1/31/19, documented the diagnosis, "Major Neurocognitive Disorder, due to syphilis." There was no evidence that a complete physical and neurological examination had been performed to rule out psychiatric symptoms due to general medical conditions or substance abuse disorders. This failure deprives treatment staff of medical knowledge that could be critical in planning individualized care.

Findings Include:

A. Medical Record Review

1. Patient A9 was admitted on 1/31/19. The Psychiatric Evaluation dictated 1/31/19 listed the following diagnoses, "Primary: Schizophrenia Spectrum and Other Psychotic Disorders; Primary: Major Neurocognitive Disorder due to syphilis; Secondary: No diagnosis at this time; Medical: Seizure disorder; Medical: Hypertension; Medical: Dysphagia; Medical: Gait imbalances."

A physical and neurological examination was attempted to be performed on 1/31/19. The patient was uncooperative. The physical examination form was labelled "unable". On 2/10/19 an entry stated, "Patient continues to be agitated with unpredictable behavior and exam could not be completed." On 2/27/19 a physician entry states, "Continue present plan of action." There was no further documentation to indicate that this patient had a complete history and physical examination.

The surveyor requested the facility to review this patient's chart to ascertain if any additional attempts were made to perform the physical examination. At 11:30 a.m. on 7/31/19, the Nurse Manager stated that she had asked someone to review the medical record, and no additional physician entries regarding the physical examination were present in the medical record.

During the exit conference on 7/31/19 at 12:00 p.m., staff provided the Nurse Manager with another physician entry dated 3/13/19 on patient A9's medical record. This entry documented an additional physician attempt to perform a physical examination which was unsuccessful. The facility did not provide any other entries which documented completion of the physical exam.

B. Interview

In an interview on 7/30/19 at 10:20 a.m., the Medical Director stated that she was aware of this lack of a physical examination for this patient and that it had been bought to her attention. The Medical Director was unsure if the exam had ever been completed.

Based on record review and interview, the facility failed to address the physical needs of one patient (A9) added to the sample in order to evaluate active treatment and did not address the patient's needs on the Master Treatment Plan (MTP). Specifically, Patient A9, who was incontinent and could be aggressive, needed assistance to shower, brush his/her teeth and complete all his/her hygiene needs did not receive the assistance needed and went for long periods of time without attending to hygiene needs. Failure to identify interventions (on the MTP) to guide staff in providing care to an aggressive patient can result in the patient's identified needs not being met, potentially impacting negatively on the patient's recovery.

Findings Include:

A. Record Review

1. Review of the "Mental Health Technician/Security Therapy Aide Review of Progress" for Patient A9 revealed the following weekly hygiene care from 6/9/19-7/27/19:

6/9/19-6/15/19-no bath/shower, no days of hair care, no teeth brushing
6/16/19-6/22/19-no bath/shower, no days of hair care, no teeth brushing
6/23/19-6/29/19-two bath/shower, three days of hair care, no teeth brushing
6/30/19-7/6/19-no bath/shower, no days of hair care, no teeth brushing
7/7/19-7/13/19-two bath/shower, six days of hair care, no teeth brushing
7/14/19-7/20/19-one bath/shower, six days of hair care, no teeth brushing
7/21/19-7/27/19-no bath/shower, six days of hair care, no teeth brushing

During this time period, (6/9/19-7/27/19) Patient A9 bathed/showered five times and did not brush his/her teeth. There was no indication that s/he was offered any alternatives for oral care or bathing.

2. Review of the "Progress Notes" for Patient A9 revealed the following episodes of incontinence:

7/3/19-1500 (3:00 p.m.) "Incontinent of urine x (times) 2."
2215 (10:15 a.m.) "Incontinent twice during shift."
7/4/19-0600 (6:00 a.m.) "Incontinent x 1."
7/5/19-0600 (6:00 a.m.) "Incontinent x 1."
7/9/19-2230 (10:30 p.m.) "Two episodes of incontinence this shift."
7/10/19-2158 (9:48 p.m.) "S/he has been incontinent of urine x 1."
7/13/19-2200 (10:00 p.m.) "Incontinent x 2 of urine this shift."
7/15/19-0600 (6:00 a.m.) "Incontinent x 1 of stool and urine."
7/17/19-0645 (6:45 a.m.) " ...showered [with] 2 assisting totally due to incontinence of stool."
7/18/19-0600 (6:00 a.m.) "Incont. [Incontinent] stool [sic] x 1 ..."
7/20/19-0600 (6:00 a.m.) "Incontinent of urine x1."
7/24/19-2200 (10:00 p.m.) "Has been incontinent x 1."
7/25/19-0620 (6:20 a.m.) " ...was wet [with] urine x 1 tonight."
7/28/19-2215 (10:15 p.m.) "Incont. X 3 of urine and stool."
7/29/19-0125 (1:25 a.m.) "Incont. large amount of urine."
10:20 a.m. (no military time) "S/he also soiled his/her pants and the nurse and all the MHTs
(Mental Health Technicians) tried to assist him/her with changing his/her clothes but s/he refused."

During this time period, there was only one "Progress Note" entry that acknowledged a shower and that was due to stool incontinence on 7/15/19. There was no indication that Patient A9 was offered any means of cleaning him/herself other than a shower.

3. Review of the MTP, dated 2/4/19, revealed the short-term goal, "[Patient] will perform ADLs as tolerated daily for 5 months with minimal staff assistance. "The intervention for this short-term goal was, "Direct care staff will assist [patient] with ADLs as needed daily while maintaining [his/her] optimal level of functioning. Staff will continue to prompt [patient] to assist them while they provide care to [him/her] daily." There were no interventions that provided
staff with approaches for dealing with Patient A9 when s/he did not want to shower or brush his/her teeth. In addition there were no goals or interventions that addressed Patient A9's incontinence and the need for providing care to maintain his/her cleanliness and prevent skin breakdown.

B. Interview

1. In interview on 7/31/19 at 9:25 a.m., MHT3 stated that Patient A9 didn't like to shower or be cleaned after soiling him/herself and that it took multiple staff to give him/her a shower.

2. In interview on 7/31/19 at 9:45 a.m., the Nurse Manager voiced surprise that Patient A9 had received so little hygiene care since 6/9/19.

Based on record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for six (6) of eight (8) sample patients (A1, A2, A5, A6, A7, and A8) and one (1) patient added to evaluate active treatment (A9). Treatment interventions listed only routine nursing discipline functions rather than individualized treatment options. This practice has the potential to lead to failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Medical Records

1. Patient A1's MTP, dated 3/17/19, listed the Problem, "Schizoaffective Disorder." For this problem, the generic nursing intervention was, "The R.N. will process psychiatric and medical medication orders, administer medications as directed, document any side effects, symptoms, and relief/progress to assist in determining the most effective medications for psychiatric stabilization, as well as, coordinate any linkage on and off AMHC [Alton Mental Health Center] campus for tests and procedures."

2. Patient A2's MTP, dated 10/19/19, listed the Problem, "Psychotic Symptoms including erotomania (a psychological disorder marked by the delusional belief that one is the object of another person's love or sexual desire) and persecutory delusions (belief others are out to harm them despite evidence to the contrary)." For this problem, the generic nursing intervention was, "RN will administer medications as prescribed daily and monitor for benefits and side effects -reporting as indicated and providing education to [Patient] regarding his/her medications at the time of administration."

3. Patient A5's MTP, dated 7/10/19, listed the Problem, "Schizoaffective Disorder." For this problem, the generic nursing intervention was, "The nurse will administer all medications as ordered, monitor for side effects, symptoms, and/or effectiveness and educate [Patient] regarding his/her mental illness at each medication pass daily."

4. Patient A6's MTP, dated 6/20/19, listed the Problem, "Schizophrenia Spectrum & Other Psychotic Disorders." For this problem, the generic nursing intervention was, "The R.N. will administer prescribed psychiatric and medical medications and monitor for effectiveness and coordinate any labs or testing as ordered by the doctor."

5. Patient A7's MTP, dated 5/20/19, listed the Problem, "Psychotic symptoms: Barrier to Discharge." For this problem, the generic nursing intervention was, "[RN name] will administer prescribed medications as indicated by the psychiatrist, evaluate symptoms during medication pass, as well as monitor for side effects and overall relief of anxiety daily and provide report to the Treatment Team for review."

6. Patient A8's MTP, dated 8/20/18, listed the Problem, "Barrier to Discharge." For this problem the generic nursing intervention was, "RN will administer medications as ordered by the physician and monitor [patient] for therapeutic benefits as well as adverse side effects."

7. Patient A9's MTP, dated 1/31/19, listed the Problem, "Schizophrenia Disorder interrelated with advanced stage Neurosyphilis with dementia symptoms, and aggression/hostility toward others." For this problem, the generic nursing intervention was, "The Nursing Staff will administer psychotropic medications prescribed both scheduled and PRN as indicated, monitoring side effects, symptoms, and relief while providing education information and structure to promote compliance"

B. Interview

In an interview on 7/31/19 at 10:00 a.m., RN1 concurred that the nursing interventions on the treatment plans were generic nursing interventions and not individualized.


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Based on record review, document review, observation, and interview the facility failed to ensure that active treatment measures, such as group and/or individual treatment, were provided for one sample patient (A6) and one patient (A9) added to the sample in order to evaluate active treatment. Specifically, Patients A6 and A9 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A6

a. Record Review

Patient A6 was admitted on 6/19/19. The Admission Psychiatric Examination, dated 6/20/19, described the psychiatric history of patient as, "When [s/he] was in the Illinois Department of Corrections [s/he] was diagnosed as seriously mentally ill. [S/he] was initially admitted to Madden Mental Health Center on December 15, 2017. [S/he] has a history of being delusional and wanting to hurt people. [S/he] has a history of hearing voices. [S/he] said [s/he] was hit in the head with a hammer when [s/he] was 17 or 18 and had a loss of consciousness."

The patient's psychiatric diagnoses listed in the Admission Psychiatric Examination were "Schizophrenia, paranoid type; Rule Out Major Neurocognitive Disorder, not otherwise specified; and Antisocial Personality Disorder."
The Social Assessment, dated 6/30/19, indicated the patient was admitted to a hospital after, "entering a Chinese restaurant claiming to be the restaurant owner and symptomatic [sic] of grandiose and disorganized thinking. Clinical records indicate patient has reported 30 prior inpatient hospitalizations."

Patient A6's MTP, dated 6/20/19, documents the Problem, "Schizophrenia Spectrum &Other Psychiatric Disorders: Psychiatric symptoms: delusions, hallucinations, rapid mood changes. Irrational and impulsive behavior, threats to kill self/others historically, intrusive boundary violating behavior with females." The Long-Term Goal for this problem was, "[Patient] will manage [his/her] mental health recovery with no violation of rights to others." The Short-Term Goal listed was, "[Patient] will participate 80% of the time in [his/her] recovery maintenance by attending Treatment Team Review meetings, adhering to [his/her] medication regime, and engaging in appropriate behavior with staff or peers." Dates for completing the Short-Term Goal was "Target Date: January 20, 20120 [sic]." There was not a goal addressing the lack of group attendance nor the provision of alternative treatment should group refusal occur.
Interventions for these goals included, "The MHT will encourage [Patient] attendance and participation in psychoeducational classes and groups specific to Life Management, and Interpersonal skill development," and "The Recovery specialist will encourage attendance and participation in Wellness Recovery Action Plan and Community Re-Entry class objectives to promote stabilization and relapse prevention within the community in the least restrictive environment possible."

b. Document Review

The Unit Treatment Schedule listed three Activity Therapy Groups, and seven Mental Health Technician groups per day Monday-Friday. Review of the facility's "Active Treatment" sheets dated, 7/13/19-7/28/19, revealed that Patient A6 reportedly had attended some of the 10 daily scheduled groups (Monday-Friday). The following days were identified as days when Patient A6 attended 50 % or less of the scheduled groups.

7/14/19-Attended 2 of 10 groups
7/15/19-Attended 2 of 10 groups
7/16/19-Attended 3 of 10 groups
7/17/19-Attended 5 of 10 groups
7/18/19-Attended 3 of 10 groups
7/19/19-Attended 3 of 10 groups
7/21/19-Attended 1 of 10 groups
7/22/19-Attended 0 of 10 groups
7/23/19-Attended 3 of 10 groups
7/24/19-Attended 2 of 10 groups
7/25/19-Attended 3 of 10 groups
7/26/19-Attended 3 of 10 groups
7/27/19-Attended 1 of 10 groups
7/28/19-Attended 3 of 10 groups

c. Observations

1. During observation on 7/29/19 at 1:25 p.m. Patient A6 was observed in bed rather than attending the scheduled group.

2. During observation on 7/30/19 at 9:40 a.m. Patient A6 was observed in bed rather than attending the scheduled group.

3. During observation on 7/30/19 at 2:30 p.m. Patient A6 was asleep in bed rather than attending the scheduled group.

d. Interviews

1. In an interview on 7/29/19 at 1:45 p.m., Patient A6 discussed with the surveyor his/her inability to remember things. S/he complained of recent memory loss. S/he did not indicate an interest in groups and denied s/he was receiving any individual attention.

2. In an interview on 7/31/19 at 9:05 a.m., RN1 indicated that Patient A6 did not go to groups. She further indicated that when in group, Patient A6 gets the handouts but either doesn't complete them or staff complete them for him/her. RN1further indicated that some of the staff think that Patient A6 is unable to read or write.

4. In an interview on 7/31/19 at 9:25 a.m., MHT3, when asked about Patient A6 attending groups, stated that s/he did not go to groups "very often." MHT3 further stated that Patient A6 often stayed in his/her room.

2. Patient A9

a. Record Review

Patient A9 was admitted on 1/31/19. The Psychiatric Evaluation, dated 1/31/19, documented the primary diagnoses as, "Schizophrenia Spectrum and other Psychotic Disorders and Major Neurocognitive Disorder, due to syphilis."
The Social Assessment, dated 2/8/19, documented the reason for transfer from another facility as ongoing combativeness and the facility's inability to stabilize his/her behavior. Patient A9 was described during this assessment as " ...state of awareness fluctuates with brief moments of seemingly reality based dialogue usually consisting of shaking [his/her] head 'yes' or 'no,' verbally answering 'yes' or 'no,' yet unable to engage a discussion of much more than one to two word responses when delirium is not present."

The initial MTP, dated 2/4/19, documented the patient's condition as, "[Patient] has a diagnoses of Advance Stage Neurosyphilis that is an ongoing deterioration of the brain that can also affect all organs ...[his/her] ability to make logical, coherent decisions is significantly affected by the brain deterioration." The Master Treatment Plan (MTP) update, dated 7/22/19, failed to include documentation to address Patient A9's inability to understand the content of many of the scheduled groups. In addition, the MTP did not address alternative therapeutic treatment measures that could replace the scheduled groups which were inappropriate for Patient A9.

b. Document Review

1. Review of the Progress Notes dated 7/2/19-7/30/19 revealed the following notes related to Patient A9.
7/2/19--"[Patient] was aggressive on 2nd shift. [S/he] attempted to punch a staff but was redirected. [S/he] also swung on [sic] another patient but was redirected."

7/3/19-"Requires redirection/prompts from staff related [sic] impulse behaviors for prevention of harm and safety measures. Continues on 1:1 observation."

7/7/19-"[Patient] continues in one to one for protection of self and others due to chronic impulsivity secondary to neuro cognitive impairment."

7/10/19-"Remains on 1:1 due to chronic agitation and impulsivity. [S/he] requires a lot of redirection and monitoring to prevent incidence [sic][with] peers."

7/13/19-"Patient showing s/o [signs of] [increased] agitation. Swings at staff and having loud episodes."

7/20/19-[Patient] chasing staff and peers, spitting on staff, swinging at peers and staff," and "In dayroom making noises."

7/24/19-[S/he] requires a lot of re-direction to prevent problems with peers."

7/27/19-[Patient] followed peer around the dayroom with his fists clenched and punching at the air."

7/29/19-"Swings and kicks at staff," and "Patient been [sic] following peer [peer medical record number] around swinging at him."

7/30/19-[Patient] was pushing writer as writer was trying to redirect ...," and "[Patient] was swinging [his/her] arm, hitting, punishing [sic] and slapping writer ... sat in chair yelling."

2. Review of the facility's "Active Treatment" sheets dated, 7/15/19-7/28/19, revealed that Patient A9 reportedly had attended some of the 10 daily scheduled groups (Monday-Friday). The following days were identified as days when Patient A9 attended 50 % or less of the scheduled groups.

7/15/19-Attended 2 of 10 groups
7/16/19-Attended 5 of 10 groups
7/17/19-Attended 3 of 10 groups
7/18/19-Attended 2 of 10 groups
7/19/19-Attended 3 of 10 groups
7/22/19-Attended 3 of 10 groups
7/23/19-Attended 4 of 10 groups
7/24/19-Attended 5 of 10 groups
7/25/19-Attended 5 of 10 groups
7/29/19-Attended 0 of 10 groups

c. Observations

1. Observation on the Locust Unit on 7/29/19 at 11:00 a.m., revealed that Patient A9 was sitting in the dayroom making loud noises and punching the air. His/her 1:1 staff was attempting to calm him/her down. There was an Activity Therapy Group (singing songs) being held in the activity room during this time.

2. Observation on the Locust Unit on 7/29/19 at 1:15 p.m., revealed that patient A9 was sitting with a 1:1 staff in the activity room but left before the MHT group started and went into the dayroom. S/he then sat in a chair and made movements like s/he was playing a guitar. The staff member asked, "[Patient] are you playing your guitar?" The patient did not respond.

3. Observation on the Locust Unit on 7/29/19 at 2:30 p.m., revealed that patient A9 was walking in the hallway with his/her 1:1 following closely behind. Patient was punching the air and making loud noises.

4. Observation on the Locust Unit on 7/30/19 at 10:15 a.m., revealed that Patient A9 was sitting in the dayroom with a 1:1 staff sitting at a table in the dayroom. The staff member (MHT1) asked patient if s/he wanted a check and s/he nodded "yes." MHT2 filled out a paper replica of a bank check made out to the patient for $800,000. MHT1, who was standing at the table, stated, "That's how we redirect him." MHT1 then gave the patient a blank sheet of paper and a large crayon. Patient A9 then began scribbling on the sheet of paper.

5. Observation on the Locust Unit on 7/30/19 at 2:30 p.m., revealed that Patient A9 was sitting with a 1:1 staff at a table in the dayroom. Patient was scribbling on a blank sheet of paper. There was a MHT group in session in the activity room.

6. Observation on the Locust Unit on 7/31/19 at 10:30 a.m., revealed that Patient A9 was sitting in a chair in the television room with the 1:1staff member sitting next to him/her. There was an activity group in session in the gym at this time.

d. Interviews

1. In an interview on 7/29/19 at 1:00 p.m., the Nurse Manager stated that Patient A9 couldn't really understand what was going on in the groups.

2. In an interview on 7/30/19 at 9:10 a.m., AT1 when asked about A9's participation in groups, stated, "It's a difficult situation with [Patient]. [S/he] is unpredictable and can be aggressive and loud." AT1 further stated that Patient A9 was restricted to the unit and could not attend groups in the gym. When asked how Patient A9 could be counted as attending several groups on the "Active Treatment" sheets, AT1 stated that he was not sure but guessed that the patient was given credit if s/he was sitting with his/her 1:1 in the dayroom and a group was being held in the dayroom.

3. In an interview on 7/30/19 at 10:15 a.m., MHT2, when asked why Patient A9 was not outside in the "big yard" with the other patients stated, "[S/he] is too much of a risk to take out there, plus s/he might fall."

4. In an interview on 7/30/19 at 2:10 p.m., MHT1 stated that Patient A9 would go to activities depending on his/her mood. When asked what the patient would do if not in a scheduled activity, MHT1 stated Patient A9 liked to walk around, play the air guitar, watch television, dance, and sing. She noted that if others got too close physically to Patient A9, s/he would make loud noises. When asked about the past weekend when she was the MHT responsible for conducting the Saturday (7/27/19) and Sunday (7/28/19) activities, MHT1 responded that she did not always follow the schedule. When asked if Patient A9 really attended the seven scheduled activities each day of the 7/27/19-7/28/19 week-end, MH1 shared that she gave credit to patients if they were up and not asleep in bed. She further stated that the patient could be sitting in the dayroom, walking in the hallway, watching television or reading a book in their room and receive a check for attending the activity on the schedule (whether or not any planned activity occurred during that time.)

5. In an interview on 7/31/19 at 9:25 a.m., MHT3 referred to Patient A9 as "a busy individual," who walked around the unit, back and forth to his/her room and was difficult to redirect. When asked if Patient A9 attended groups, MHT3 replied that s/he did not cooperate in groups and usually left or had to be escorted out with assistance from the 1:1 and another staff member. When asked how she gave credit for activities on the week-end, MHT3 stated that she gave credit for activities when patients were up and not in bed asleep.

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

1. The provision of a complete physical and neurological examination for one of nine patients selected (Patient A9). The Psychiatric Evaluation, dated 1/31/19, documented the diagnosis, "Major Neurocognitive Disorder, due to syphilis." There was no evidence that a complete physical and neurological examination had been performed to rule out psychiatric symptoms due to general medical conditions or substance abuse disorders. This failure deprives treatment staff of medical knowledge that could be critical in planning individualized care. (Refer to B109)

2. The provision of active treatment measures, such as group and/or individual treatment, were provided for one sample patient (A6) and one patient (A9) added to the sample in order to evaluate active treatment. Specifically, Patients A6 and A9 were unable or unwilling to attend their scheduled treatment groups and failed to have therapeutic alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Interview

In an interview on 7/30/19 at 10:20 a.m., the Medical Director stated that she was aware of this lack of a physical examination for this patient and that it had been bought to her attention. The Medical Director was unsure if the exam had ever been completed.

In addition, the Medical Director was informed of the findings regarding the lack of active treatment for patients who refused to participate in the groups offered and the lack of active treatment alternatives being provided. The Medical Director acknowledged her understanding of the surveyor's findings.

Based on record review and interview, the Director of Nursing failed to ensure that:

1. Nursing staff addressed the physical needs of one patient (A9) added to the sample in order to evaluate active treatment and did not address the patient's needs on the Master Treatment Plan (MTP). Specifically, Patient A9, who was incontinent and could be aggressive, needed assistance to shower, brush his/her teeth and complete all his/her hygiene needs did not receive the assistance needed and went for long periods of time without attending to hygiene needs. Failure to identify interventions (on the MTP) to guide staff in providing care to an aggressive patient can result in the patient's identified needs not being met, potentially negatively impacting on the patient's recovery. (Refer to B118)

2. Nursing interventions were based on the individual needs of the patients for six of eight sample patients (A1, A2, A5, A6, A7, and A8) and one patient added to evaluate active treatment (A9). Nursing interventions listed only routine nursing discipline functions rather than individualized treatment options. This practice has the potential to lead to failure of individualized treatment interventions and to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

Based on document review and interview, the facility failed to provide qualified therapists and support personnel to ensure that patients were provided ongoing treatment. Specifically, there were limited therapeutic and leisure activities offered on the week-ends. Any leisure activities offered on Saturday and Sunday were provided by Mental Health Technicians (MHTs). The specific activities were dependent on the individual MHT assigned to offer groups who could decide what activities and how many, if any, to offer. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process.

Findings Include:

A. Document Review

Review of the week-end Active Treatment sheets revealed that they contained the same time slots as the Monday-Friday (M-F) Active Treatment sheets. Unlike the M-F sheets, the week-end sheets did not have specific groups assigned to the time slots. Each time slot merely had "Activity" listed but did not direct the MHTs to conduct any particular activity.

B. Interviews

1. In an interview on 7/30/19 at 9:10 a.m., AT1 shared that the only Activity Therapy (AT) groups offered on week-ends were "Incentive" groups which consisted of popcorn and movies which were provided to patients who had earned enough points through attending groups. When asked how many patients were usually in attendance for the groups, AT1 stated that the previous week-end he had eight patients attending. When asked what the other patients (7 patients) were doing during this time, he responded that he did not know.

2. In an interview on 7/30/19 at 2:10 p.m., MHT1, when asked about the weekend schedule, responded that they (MHTs) did not always follow the schedule on the week-ends. She further stated that they always had the morning and evening Community Meetings, which were the only mentioned groups on the schedule, and had fresh air twice a day.

3. In an interview on 7/31/19 at 9:25 a.m., MHT3 stated that the schedule on the week-ends was more relaxed than during the week and that they (MHTs) did not always follow the schedule of an activity in each time slot.