HospitalInspections.org

Based on observation, interview, and record review, the hospital was found to be out of compliance with standard tag/s related to lack of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings included:

Please refer to Life Safety Code inspection tags: K-0029, K-0062, K-0067 and K-0144 for additional information.

Based on record review and interview, this facility failed to provide psychosocial assessments for eight (8) of eight (8) active sampled records (A1, A2, A3, A4, A6, A7, A9, and A10) that included conclusions and recommendations for social work roles that could be utilized during the treatment and discharge planning for the patients. This failure of documentation of conclusions and recommendations has the potential to compromise team planning for treatment and discharge for each individual patient and potentially delay discharge.

Findings Include:

A. Record Review

Social Service Assessments for Patient A1 dated 3/28/14, Patient A2 dated 3/14/14, Patient A3 dated 4/7/14, Patient A4 dated 3/17/14, Patient A6 dated 2/27/14, Patient A7 dated 11/21/13,
Patient A9 dated 3/21/14, and Patient A10 dated 3/6/14 did not include diagnostic formulations and conclusions.

B. Staff Interviews

1. In an interview on 4/7/14 at 10:00 a.m. the Director of Social Services concurred that the current format for social assessments does not require the inclusion of a formulation and conclusion of the patient's information.

2. In an interview on 4/7/14, Social Worker 3 concurred that the social assessments did not contain formulations and conclusions based on the patient's information.

Based on observation, record review, and interview, the facility failed to ensure that active treatment groups were included on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A6, A7, A9, and A10) who attended groups listed on the "Patient Recovery Schedule. In addition, the facility failed to provide seven (7) of eight (8) active sample patients (A1, A2, A4, A6, A7, A9, and A10) with MTPs which included individualized interventions based on each patient's individual presenting problems. Instead, the MTPs contained generic and routine discipline functions written as treatment interventions. These interventions were actually discipline tasks that would be performed regardless of the patient's specific psychiatric problems. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

I. Failure to include groups attended by patients on MTPs

A. Observation, Record Review, and Interview

1. During observation in the Group Room on 4/7/14 at 10:10 a.m., Patients A6 and A7 attended a group listed on the "Patient Recovery Schedule" as "Anger Management" which was conducted by OT1. During observation on 4/7/14 at 1:00 p.m., these patients also attended a "Coping with Stress" group. These groups were not included on Patient A6's MTP dated 2/28/14 (updated weekly) and not included on Patient A7's MTP dated 11/23/14 (updated weekly). During interview on 4/7/14 at 10:55 a.m., OT1 confirmed that the Anger Management Group was not assigned on the MTPs for Patients A6 and A7.

2. During observation on 4/8/14 at 9:30 a.m., Patients A1, A6, and A7 attended a group listed on the "Patient Recovery Schedule" as "Nursing Focus." This group conducted by RN4 focused on problem solving using a current problem each patient wrote on paper and placed in a box. This group was not included on these patients' MTPs. During interview at 10:15 a.m. after the group, RN4 confirmed that the "Nursing Focus" group was not included on the treatment plan and stated, "We have not been taught to place groups on the treatment plan." She stated that they offer Engagement and Focus groups and all patients were on the Engagement Track and those patients who were ready for more detailed education were placed on the Focus Track.

3. During observation on 4/8/14 at 11:00 a.m., Patient A1 with an interpreter attended a group listed on the "Patient Recovery Schedule" as "Chemical & Mental Health/Community Resources." This group conducted by SW1 focused on community survival issues. Patient A1 left at 11:30 a.m. and did not return. This group was not on the patient's MTP.

B. Record and Document Review

A review of the document that the facility used to track the attendance of patients in active treatment groups was reviewed. This document was compared with the MTPs for the following patients (original dates of plans in parentheses). Plans were updated weekly: A1 (3/31/13); A2 (3/18/14); A3 (4/7/14); A4 (3/17/14); A6 (2/28/14); A7 (11/23/14); A9 (3/21/14); and A10 (3/13/14). This comparison revealed that the following active sample patients attended groups during the period from 4/1/14 through 4/8/14 and were not included on their MTPs.

1. Patient A1 attended 14 groups during the period from 4/1/13 through 4/8/14 and the attendance document listed four (4) "Engagement Groups" and 10 "Focus" groups which included but not limited to the following groups, "Patient Recovery Schedule", "Community Resources, Peer Interaction, and Healthy Living." These groups were not included on the patient's MTP.

2. Patient A2 attended 35 groups during the period 4/1/14 through 4/8/14 which included but not limited to the following groups, four (4) "Engagement Groups," 14 "Focus" groups, four (4) "Creative Expression" group, one (1) "OT Clinic" group, and "Healthy Living" group. The only group on the MTP from the list above was the "Creative Expression" group.

3. Patient A3 attended 15 groups during the period from 4/3/14 to 4/8/14 which included but not limited to the following groups, five (5) "Engagement Groups," four (4) "Creative Expression" groups, and one (1) "OT Clinic" group. These groups were not included on the patient's MTP.

4. Patient A4 attended six (6) groups during the period from 4/1/14 to 4/8/14 which included one (1) "Engagement Groups," "two (2) Creative Expression" groups, two (2) "Healthy Living" group, and one (1) "Sensory Group." These groups were not included on the patient's MTP.

5. Patient A6 attended 20 groups during the period from 4/1/14 to 4/8/14 which included but not limited to the following groups, nine (9) "Focus" groups, four (4) "Creative Expression" groups, "one (1) Sensory Group," and one (1) "OT Clinic" group. The only group on the MTP from the list above was the "OT Clinic" group.

6. Patient A7 attended 18 groups during the period from 4/1/14 to 4/8/14 which included but not limited to the following groups, three (3) "Engagement Groups," seven (7) "Creative Expression" groups, five (5) "Healthy Living" groups, and one (1) "Sensory Group." The only group on the MTP from the list above was the "Creative Expression" group.

7. Patient A9 attended 27 groups during the period from 4/1/14 to 4/8/14 which included but not limited to the following groups eight (8) "Engagement Groups," four (4) "Creative Expression" groups, and four (4) "Focus" groups. The only group on the MTP from the list above was the "Creative Expression" group.

8. Patient A10 attended 30 groups during the period from 4/1/14 to 4/8/14 which included but not limited to the following groups, five (5) "Engagement Groups," 11 "Focus" groups, five (5) "Creative Expression" groups, and two (2) "OT Clinic" group. The only group on the MTP from the list above was the "Creative Expression" group.

II. Generic and routine discipline tasks written as interventions

A. Record Review

The MTPs for the following patients were reviewed (original dates of plans in parentheses). Plans were updated weekly: A1 (3/31/13); A2 (3/18/14); A3 (4/7/14); A4 (3/17/14); A6 (2/28/14); A7 (11/23/14); A9 (3/21/14); and A10 (3/13/14). This review revealed that the MTPs contained the following generic and routine discipline tasks written as treatment interventions to be delivered by the psychiatrist [MD], registered nurse (RN), and occupational therapist (OT).

1. Patient A1 had the following generic and routine discipline functions written as treatment interventions for the problem, "...exhibiting paranoia, agitation, and anxiety..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] thought processing and degree of anxiety...while reviewing more about his history..."

OT Intervention: - "OT will meet with [Patient's name] at least once this week to assess [his/her] current skills in managing [his/her] illness and meeting new sober friends."

2. Patient A2 had the following generic and routine discipline functions written as treatment interventions for the problem, "...experiencing intermittent, intense, intrusive thoughts that are very distressing to [him/her]..."

OT Intervention: - "OT will meet with [Patient's name] at least once this week to complete an occupational profile to better understand [his/her] routine at home..."

RN Intervention: - "RN will meet with [Patient's name] daily to discuss [his/her] progress in developing a schedule..." "Nursing staff will encourage/remind [Patient's name] to stick to [his/her] daily schedule..."

3. Patient A4 had the following generic and routine discipline functions written as treatment interventions for the problem, "...had a decompensation in [his/her] mental health as evidenced by disorganized thinking, rambling ... "

MD Intervention: - "LIP will meet with [Patient's name] three times this week to monitor [his/her] progress related to [his/her] current medication regimen while assessing the need for any changes."

4. Patient A6 had the following generic and routine discipline functions written as treatment interventions for the problem, "...self injurious behavior has increased..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] progress with [him/her] emotional regulation skills..."

OT Intervention: - "OT will meet with [Patient's name] at least once this week to complete a leisure assessment to determine activities [s/he] would like to do in [his/her] unstructured time."

RN Intervention: - "RN will meet with [Patient's name] at least four times to review [his/her] plan for how to better get along with staff and peers."

5. Patient A7 had the following generic and routine discipline functions written as treatment interventions for the problem, "...had experienced continued mental problems as evidenced by persistent suicidal ideations and behaviors..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to monitor [his/her] ability to control [his/her] feelings while assessing [his/her] readiness for discharge."

RN Intervention: - "RN will encourage [Patient ' name] to socialize with [his/her] peers daily..."

6. Patient A9 had the following generic and routine discipline functions written as treatment interventions for the problem, "...has had a decompensation in [his/her] mental health symptoms as evidenced by yelling at family, attempting suicide..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] progress in terms of [his/her] sleep, thought processing..."

OT Intervention: - "OT will meet with [Patient's name] at least once this week to have a conversation to assess [his/her] communication needs and how OT services can assist [him/her]."

RN Intervention: - "RN will provide feedback to [Patient's name] on a daily to assess [his/her] ability to receive this feedback..." "RN will meet with [Patient's name] for at least 5 minutes daily to assess [his/her] progress in communicating [his/her] needs."

7. Patient A10 had the following generic and routine discipline functions written as treatment interventions for the problem, "... has had a decompensation in [his/her] evidenced by [him/her] stopping [his/her] medications....experiencing intermittent, intense, intrusive thoughts that are very distressing to [him/her]..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] thought processing and response to risperidone..."

OT Intervention: - "OT will meet with [Patient's name] at least once this week to create a basic daily schedule incorporating [his/her] current attention span..."

RN Intervention: - "RN will meet with [Patient's name] daily to discuss [his/her] progress in developing a schedule..." "Nursing staff will encourage [Patient's name] to attend groups..."

B. Staff Interviews

1. During a treatment planning meeting held on 4/7/14 at 2:00 p.m. with the Medical Director, RN4, SW2, and an OT student intern, the formulation of treatment interventions on the treatment plan was discussed. The Medical Director acknowledged some interventions on the treatment plans were generic and routine discipline functions and stated, "It seems to be just a matter of wording."

2. During interview on 4/8/14 at 3:35 p.m. with the Director of Nursing (DON) and RN1, the treatment interventions on the MTPs were discussed. The DON confirmed that MTPs contained some intervention statements that were routine and generic nursing tasks.

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

I. Ensure that psychosocial assessments for eight (8) of eight (8) active sampled records (A1, A2, A3, A4, A6, A7, A9, and A10) included conclusions and recommendations for social work roles that could be utilized during the treatment and discharge planning for the patients. This failure of documentation of conclusions and recommendations has the potential to compromise team planning for treatment and discharge for each individual patient and potentially delay discharge. (Refer to B108)

II. Ensure that active treatment groups were included on the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A6, A7, A9, and A10) who attended groups listed on the "Patient Recovery Schedules." Failure to include all active treatment groups hampers the staff's ability to provide coordinated care and treatment, potentially resulting in the treatment needs of patients not being met. (Refer to B122)

III. Develop individualized treatment interventions to be delivered by the psychiatrist for six (6) of eight (8) active sample patients (A1, A4, A6, A7, A9, and A10). Specifically, the MTPs contained generic and routine physician functions written as treatment interventions. These treatment interventions were actually physician tasks that would be performed regardless of the patient's specific psychiatric problems. This deficiency results in the facility not clearly delineating the role of psychiatrists in the treatment of patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses). Plans were updated weekly: A1 (3/31/13); A2 (3/18/14); A3 (4/7/14); A4 (3/17/14); A6 (2/28/14); A7 (11/23/14); A9 (3/21/14); and A10 (3/13/14). This review revealed that the MTPs contained the following generic and routine tasks written as treatment interventions to be delivered by the psychiatrist [MD].

1. Patient A1 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "...exhibiting paranoia, agitation, and anxiety..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] thought processing and degree of anxiety...while reviewing more about his history..."

2. Patient A4 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "... had a decompensation in [his/her] mental health as evidenced by disorganized thinking, rambling..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to monitor [his/her] progress related to [his/her] current medication regimen while assessing the need for any changes."

3. Patient A6 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "...self injurious behavior has increased..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] progress with [him/her] emotional regulation skills..."

4. Patient A7 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "...had experienced continued mental problems as evidenced by persistent suicidal ideations and behaviors..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to monitor [his/her] ability to control [his/her] feelings while assessing [his/her] readiness for discharge."

5. Patient A9 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "...has had a decompensation in [his/her] mental health symptoms as evidenced by yelling at family, attempting suicide..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] progress in terms of [his/her] sleep, thought processing..."

6. Patient A10 had the following generic and routine psychiatrist function written as treatment interventions for the problem, "... has had a decompensation in [his/her] evidenced by [him/her] stopping [his/her] medications....experiencing intermittent, intense, intrusive thoughts that are very distressing to [him/her]..."

MD Intervention: - "LIP will meet with [Patient's name] three times this week to review [his/her] thought processing and response to risperidone..."


B. Staff Interview


1. During a treatment planning meeting held on 4/7/14 at 2:00 p.m. with the Medical Director, RN4, SW2, and an OT student intern, the formulation of treatment interventions on the treatment plan was discussed. The Medical Director acknowledged some interventions on the treatment plans were generic and routine discipline functions and stated, "It seems to be just a matter of wording."

IV. Provide adequate numbers of qualified Therapeutic Activities staff [called Rehabilitation Therapy staff by the facility] to complete assessments following each patient's admission and provide appropriate input into the formulation of the MTP. Specifically, because of insufficient Therapeutic Activities/Rehabilitation Therapy staff, there were no assessments completed for six (6) of eight (8) active sample patients (A2, A3, A4, A6, A9, and A10). In addition, there was no Therapeutic Activity/Rehabilitation Therapy staff to provide activities after 4:00 p.m. and on weekends. Nursing staff, especially Human Service Technicians (HSTs), were assigned to conduct groups after hours and on weekends. HSTs received general training regarding conducting groups but no specific training for the therapeutic activity groups provided. These failures result in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning. (Refer to B158)

Based on record review and interview, the Director of Nursing (DON) failed to provide adequate oversight to ensure quality nursing services. Specifically, the DON failed to ensure that MTPs for five (5) of eight (8) active sample patients (A2, A6, A7, A9, and A10) included individualized nursing interventions based on each patient's individual presenting problems. Instead, the MTPs contained generic and routine nursing functions written as treatment interventions. These statements were actually nursing tasks that would be performed regardless of the patient's specific psychiatric problems. This deficiency results in a failure to guide nursing staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses). These plans were updated weekly: A1 (3/31/13); A2 (3/18/14); A3 (4/7/14); A4 (3/17/14); A6 (2/28/14); A7 (11/23/14); A9 (3/21/14); and A10 (3/13/14). This review revealed that the MTPs contained the following generic and routine nursing tasks written as treatment interventions to be delivered by the registered nurse (RN).

1. Patient A2 had the following generic and routine nursing functions written as treatment interventions for the problem, "...experiencing intermittent, intense, intrusive thoughts that are very distressing to [him/her]..."

RN Intervention: - "RN will meet with [Patient's name] daily to discuss [his/her] progress in developing a schedule..." "Nursing staff will encourage/remind [Patient's name] to stick to [his/her] daily schedule..."

2. Patient A6 had the following generic and routine nursing function written as treatment interventions for the problem, "...self injurious behavior has increased..."

RN Intervention: - "RN will meet with [Patient's name] at least four times to review [his/her] plan for how to better get along with staff and peers.

3. Patient A7 had the following generic and routine nursing function written as treatment interventions for the problem, "... had experienced continued mental problems as evidenced by persistent suicidal ideations and behaviors..."

RN Intervention: - "RN will encourage [Patient's name] to socialize with [his/her] peers daily..."

4. Patient A9 had the following generic and routine nursing functions written as treatment interventions for the problem, "...has had a decompensation in his mental health symptoms as evidenced by yelling at family, attempting suicide..."

RN Intervention: - " RN will provide feedback to [Patient's name] on a daily to assess [his/her] ability to receive this feedback ..." " RN will meet with [Patient's name] for at least 5 minutes daily to assess [his/her] progress in communicating [his/her] needs."

5. Patient A10 had the following generic and routine nursing functions written as treatment interventions for the problem, "...has had a decompensation in her evidenced by [him/her] stopping [his/her] medications....experiencing intermittent, intense, intrusive thoughts that are very distressing to [him/her]..."

RN Intervention: - "RN will meet with [Patient's name] daily to discuss [his/her] progress in developing a schedule..." "Nursing staff will encourage [Patient's name] to attend groups..."

B. Staff Interview

During interview on 4/8/14 at 3:35 p.m. with the Director of Nursing (DON) and RN1, the interventions on the MTPs were discussed. The DON confirmed that MTPs contained some intervention statements that were routine and generic nursing tasks.

The Director of Social Work failed to ensure that psychosocial assessments for eight (8) of eight (8) active sampled records (A1, A2, A3, A4, A6, A7, A9, and A10) included conclusions and recommendations for social work roles that could be utilized during the treatment and discharge planning for the patients. This failure of documentation of conclusions and recommendations has the potential to compromise team planning for treatment and discharge for each individual patient and potentially delay discharge. (Refer to B108)

Based on record review, document review, and staff interview, the facility failed to provide adequate numbers of qualified Therapeutic Activities staff [called Rehabilitation Therapy staff by the facility] to complete assessments following each patient's admission and provide appropriate input into the formulation of the Master Treatment Plans (MTPs). Specifically, because of insufficient rehabilitation therapy staff, there were no assessments completed for six (6) of eight (8) active sample patients (A2, A3, A4, A6, A9, and A10). In addition, there was no Therapeutic Activity/Rehabilitation Therapy staff to provide active treatment after 4:00 p.m. and on weekends. Nursing staff, especially Human Service Technicians (HSTs), were assigned to conduct groups after hours and on weekends. HSTs received general training regarding conducting groups but no specific training for the therapeutic activity groups provided. These failures result in lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings include:

A. Staff Interviews

1. During interview on 4/8/14 at 10:15 a.m., with OTR (Registered Occupational Therapist) 1, the facility's Therapeutic Activity Program was discussed. OTR 1 stated that they had a COTA (Certified Occupational Therapy Assistant) employed until the middle of January 2014. She stated, since that time, she has been conducting three (3) to four (4) groups per day and that nursing staff were assigned to do some of the groups that were usually conducted by the COTA. She noted that she conducts groups Monday through Friday and nursing staff was responsible for groups after hours and on weekends. OTR 1 stated that she meets with each patient within a week of admission to do an assessment. She stated, "I also do an assessment while the patient is in group." OTR1 stated that the rehabilitation program included, "OT Clinic, Independent Living, sensory group, five of the 21 groups in the IMR (Illness Management Recovery) Program five (5) of the 21 groups in the IMR (Illness Management Recovery) Program Leisure Exploration, and Creative Exploration. The latter two (2) groups were assigned to nursing staff.

2. During interview on 4/8/14 at 12:25 p.m. with the Director of Nursing (DON) and the Project Consultant for facility, the competency of two HSTs (HST1 and HST2) on the assignment sheets to conduct Therapeutic Activity groups was discussed. The Project Consultant stated that all staff received basic training in how to do group. After reviewing the Competency Folders for these two (2) HSTs, the DON and Project Consultant confirmed that there was no competency assessment i.e. posttest or return demonstration found in their competency folders.

3. During interview on 4/8/14 at 1:30 p.m., HST1 confirmed that she conducts the "Creative Express Group" listed on the Unit Schedule. When asked about training to do this group, she stated, "I was trained by the previous HST who did the group." She admitted that she had no received any other specific training to do the "Creative Expression" group.

B. Document and Record Review

1. The facility's Policy #16610, entitled "Adult Mental Health: Assessment" failed to include procedures and time frames for the completion of a therapeutic activities/rehabilitation therapy assessment. This policy stipulated that, "A comprehensive plan that directs the provision of treatment and interventions on the basis of assessment and continued reassessment..." In addition, the facility's "Service Delivery Plan & Scope of Practice: Rehabilitation Therapy" stipulated that, "...the Occupational Therapy Department completes a functional evaluation with each patient upon admission and, if possible, prior to the development of the treatment plan." Despite these policy requirements, there were no therapeutic activities/rehabilitation assessments found to be used in the formulation of the MTPs for six (6) of eight (8) active sample patients (A2, A3, A4, A6, A9, and A10).

2. A review of the medical record revealed that there was no assessment to determine appropriate therapeutic activities/rehabilitation therapies for the following patients:

a. Patient A2 was admitted 3/14/14 with a diagnosis of Schizoaffective Disorder. There was no assessment completed for this patient, despite an Occupational Therapy intervention being included on his/her MTP dated 3/18/14 and updated on 3/25/14 and 4/1/14.

b. Patient A3 was admitted on 4/3/14 with a diagnosis of Schizoaffective Disorder. Although, the patient's MTP was formulated on 4/7/14, there was no assessment to determine appropriate therapeutic activities for this patient.

c. Patient A4 was admitted 3/14/14 with a diagnosis of Schizoaffective Disorder. There was no assessment completed for this patient, despite an Occupational Therapy intervention included on the MTP updated on 3/31/14.

d. Patient A6 was admitted 2/25/14 with a diagnosis of Recurring Major Depression, in remission. There was no activity therapy assessment completed until 4/7/14, despite an Occupational Therapy intervention included on his/her MTP dated 2/28/14 and updated on 3/7/14, 3/14/14, 3/21/14, and 4/4/14.

e. Patient A9 was admitted 3/19/14 with a diagnosis of Schizophrenia. The MTP updated 3/26/14 and 4/2/14 for the patient contained an Occupational Therapy intervention. However, there was no assessment completed to show the correlation between assessed need and service being provided. [Note: There was a draft of a draft document on the electronic record system dated 3/31/14. As of 4/8/14, this document had not been finalized.]

f. Patient A10 was admitted 3/4/14 with a diagnosis of Schizoaffective Disorder. There was no assessment, despite an Occupational Therapy intervention included on his/her MTP dated 3/13/14 and updated on 3/20/14, 3/27/14, and 4/3/14.

3. A review of the "Patient Recovery Schedule" "PU Daily Activity Schedule" showed that one (1) group "Creative Expression" was offered at 6:00 p.m. seven days per week. The schedule also showed that "Leisure Exploration" was offered Saturday and Sunday at 10:00 a.m. and was to be offered one time per day for 1 hour Monday through Sunday. According to OTR1, nursing staff especially HSTs were responsible for conducting these therapeutic activities under the auspices of Therapeutic Activities/Rehabilitation Services.

4. The staff assignment for 4/5/14 through 4/8/14 showed that HSTs were assigned to conduct the Creative and Leisure Exploration. A review of the training record of training for two of the se HSTs assigned to do these groups revealed only general training to conduct groups and there was no specific training regarding these two groups. A review of the "Nursing Orientation HST Competency Evaluation" revealed that for the training entitled, "...Group facilitation -activity skills group," there was a requirement for the, "Completion of a posttest and an evaluation when working with patients on the treatment unit." These competency assessments were not found for HST1 and HST2.

5. The facility failed to provide a comprehensive program description of the therapeutic and rehabilitative activities used to develop and maintain adaptive skills as well as leisure skills for the patient population they serve. The only document available was the "Service Delivery Plan & Scope of Practice: Rehabilitation Therapy which primarily provided information about Occupational Therapy."