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Based on record review and interview, the hospital failed to ensure the training and experience of all personnel was adequate to meet the needs of the patient's as evidenced by failing to ensure all direct care staff maintained certification in de-escalation techniques for 1 (S7MHT) of 4 personnel records reviewed. This deficient practice had the potential to negatively impact the 14 patients on census at the time of survey.

Findings:

Review of the hospital 2019 Staff Development Plan given to surveyor by S6EH revealed in part: Employees with direct patient care responsibilities will obtain and maintain current certification in environmental de-escalation guidance education (EDGE). Employees must attend certification classes which are routinely held on-site.

Review of S7MHT employee file revealed a date of hire of 09/27/17. Further review revealed EDGE certification had expired on December 2018.

Interview on 01/15/19 at 9:45 a.m. with S6EH confirmed that S7MHT EDGE certification was not current and stated that she did not know why s7MHT had not been recertified.

Based on record review and interview, the hospital failed to ensure each patient had an individualized comprehensive treatment plan as evidenced by failing to ensure the patient's Treatment Plan included individualized, measurable goals and interventions for Activity's for 5 (#1, #2, #3, #4, and #5) of 5 sampled patients.

Findings:

Review of the policy titled "Treatment Plans", Document Number PC-501, dated July 10, 2012 revealed in part: To identify, evaluate, and update care and services appropriate to the individual's specific needs in order to promote therapeutic progress and provide treatment direction. B. Initial Treatment Plan. 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. This initial treatment plan is utilized to implement immediate treatment objectives. a) Therapeutic efforts begin when the initial treatment plan is developed. b) Problems are added to the problem list as they occur.

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Patient #1
Record review on 01/14/19 revealed patient #1 was admitted to the hospital on 01/08/19 with a diagnosis of Psychosis. Further review revealed an Activity assessment dated 01/09/19 had listed
Strengths: Task Performances, Motivation, Values relationship with family, and Positive self-image.
Weaknesses: Negative use of leisure time skills, Self-expression skills, and Stress management skills. Further review of Treatment Plan dated 01/10/19 listed patient #1 Goals for Activity: Patient will return to previous level of effective functioning:
Objectives:
1. Patient will participate in therapeutic groups to the best of his ability 75% of the time.
2. Patient will accept and understand that distressing symptoms are due to mental illness
Interventions:
1. Patient will attend activity group 1 x day, 3 days/week, for 45 minutes each.
There was no other documentation to reflect individualized measurable goals and interventions for activities for patient #1.

Patient #2
Record review on 01/14/19 revealed patient #2 was admitted to the hospital on 01/04/19 with a diagnosis of Psychosis, and a history of Schizophrenia. Review of the Activity assessment dated 01/07/19 had listed:
Strengths: Desire, Motivation, and Verbal.
Weaknesses: Coping skills, Communication skills, and Stress management skills.
Further review of Treatment Plan dated 01/07/19 listed patient #2 Goals for Activity: Patient will return to previous level of effective functioning.
Objectives:
1. Patient will accept and understand that distressing symptoms are due to mental illness.
2. Patient will participate in therapeutic groups to the best of his ability 75% of the time.
Interventions:
1. Patient will attend activity group 1 x day, 3 days/week, for 45 minutes each.
2. Patient will attend psychotherapy group 1 x day, 3 days/week, for 45 minutes each.
There was no other documentation to reflect individualized measurable goals and interventions for activities for patient #2.

Patient #3
Record review on 01/14/19 revealed patient #3was admitted to the hospital on 01/02/19 with a diagnosis of Psychosis. Review of the Activity assessment dated 01/04/19 had listed
Strengths: Daily living skills, Motivation, and Verbal.
Weaknesses: Task performances, Self-expression skills, Self-control, Coping skills, Communication skills, Social skills, Frustration tolerance level, and Stress management skills. Further review of Treatment Plan dated 01/07/19 listed patient #3 Goals for Activity: Patient will return to previous level of effective functioning
Objectives:
1. Patient will participate in therapeutic groups to the best of his ability 75% of the time.
2. Patient will accept and understand that distressing symptoms are due to mental illness.
Interventions:
1. Patient will attend activity group 1 x day, 3 days/week, for 45 minutes each.
2. Build trust and establish therapeutic rapport with patient.
3. Patient will attend group therapy 3 x week.

There was no other documentation to reflect individualized measurable goals and interventions for activities for patient #3.

Patient #4
Record review on 01/14/19 revealed patient #4 was admitted to the hospital on 01/08/19 with a diagnosis of MDD with Psychosis Postpartum. Review of Activity assessment dated 01/09/19 had listed
Strengths: Values relationship with family, Verbal, and Positive self-image.
Weaknesses: Self-Control, Coping Skills, Social Skills, and Stress management skills.
Further review of the Treatment Plan dated 01/10/19 listed patient #4 Goals for Activity: Patient will develop the ability to recognize, accept, and cope with feelings of depression.
Objectives:
1. Patient will participate in therapeutic groups to the best of her ability 75% of the time.
2. Patient will make positive statements about self and the ability to cope with life stressors.
Interventions:
1. Patient will attend activity group 1 x day, 3 days/week, for 45 minutes each.
2. Build trust and establish therapeutic rapport with patient.
There was no other documentation to reflect individualized measurable goals and interventions for activities for patient #4.

Patient #5
Record review on 01/14/19 revealed patient #5 was admitted to the hospital on 01/04/19 with a diagnosis of Psychosis with Bipolar Disorder. Review of Activity assessment dated 01/07/19 had listed
Strengths: Knowledge of Leisure Time Skills, Daily Living Skills, and Verbal.
Weaknesses: Task Performances, Relating to Authority Figures, Self-expression skills, Self-Control, Communication Skills, and Social Skills. Further review of the Treatment Plan dated 01/08/19 listed patient #5 Goals for Activity: Patient will return to previous level of effective functioning
Objectives:
1. Patient will understand and accept that distressing symptoms are due to mental illness
2. Patient will participate in therapeutic groups to the best of his ability 75% of the time.
Interventions:
1. Patient will attend activity group 1 x day, 3 days/week, for 45 minutes each.
2. Staff will build trust and establish therapeutic rapport with patient.
There was no other documentation to reflect individualized measurable goals and interventions for activities for patient #5.

Interview on 01/14/19 at 2: 35 p.m. with S2DON confirmed the Treatment Plans did not reflect individualized goals and interventions for Activities for the patients.

Based on record reviews and interview, the hospital failed to ensure activity assessments were conducted by qualified therapists as evidenced by having no documented evidence S3AD possessed a degree in therapeutic recreation from a post-secondary institution or a degree in another field of study and had attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements or had a minimum of 10 years' experience providing therapeutic recreational services. S3AD completed and documented the activity assessments for 2 (#3, #5) of 5 patient records reviewed for activity assessments and S5Intern completed and documented the activity assessments for 3 (#1, #2, #4) of 5 from a sample of 5 patients.

Findings:

Review of S3AD personnel file revealed a date of hire of 12/21/17. S3AD had a Bachelor's degree in Psychology. Further review revealed no documented evidence she was certified by the National Council for Therapeutic Recreation Certification. There was no documented evidence she had a minimum of 10 years' experience providing therapeutic recreational services.

Review of the medical records for patients #3, and #5 revealed their activity assessments were conducted by S3AD.

Review of the medical records for patients #1, #2, and #4 revealed their activity assessments were conducted by S5Intern.


Interview on 01/15/19 at 8:35 a.m. with S1Administrator revealed S5Intern was not a paid employee of the hospital. S1Administrator further stated that she had started last week doing an internship at the hospital and was unaware that she was completing the activity assessments on patients unsupervised.

Interview on 01/15/19 at 10:30 a.m. with S5Intern from GSU confirmed that she was a student doing her internship at the hospital. S5Intern confirmed that she did complete the activity assessment for patient #1, #2, and #4 and also stated that there were no other hospital staff present during the assessments.