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Based on interview and record review the facility failed to follow physician orders for documentation of administration of medication for one (#6) of 34 patients reviewed for medication administration from a total of 36, resulting in the potential for adverse outcomes. Findings include:

On 12/12/17 beginning at 0900 review of the clinical record for patient #6 revealed an admission on 8/15/17 and discharge on 8/22/17. The initial nurse assessment dated 8/15/17 at 0100 noted patient reported becoming very angry after having seizures. Patient reports last seizure was 7/24/17. The history and physical exam dated 8/15/17 documented patient reports she is under a lot of stress from having a seizure disorder. Further review of the clinical record revealed a physician order signed by a facility medical physician on 8/15/17 for Keppra (anti-seizure medication) 500 mg (milligrams) one by mouth every day for three days then twice a day for diagnosis of seizure. Review of the medication administration record dated 8/21/17 documented an order for Keppra 500 mg (milligrams) one by mouth twice daily-start 8/19. The administration times were documented at 0900 and 1700. The record documented nurse initials indicating the Keppra was given at 0900. The 1700 administration time was blank. There were no notations on the back of the medication administration record to indicate why the medication had not been given. No nursing progress notes documenting why the medication was not given were found in the clinical record.

On 12/13/17 at 1053 the facility Director of Nursing (DON), Staff D was queried regarding the blank administration time for Keppra on 8/21/17. Staff D reviewed the clinical record and stated "It looks like it was not given, the nurse should have documented that it was not given and why. What is disappointing is the administration record is signed indicating it was reviewed also and nothing was noted regarding the missed dose, but the nurse did note just below it that the lithium level was done." Staff D reviewed the clinical record further and stated she did not see any progress notes that addressed the missed dose of Keppra, adding "the interdisciplinary team note on 8/21/17 documented the patient was compliant with medications."

On 8/13/17 at 1745 the facility policies for medications were reviewed. Policy 7.000 titled "Medication Safety Plan/Policy" dated revised 10/2016 documented the following: "Policy-It is the policy of (hospital name) that physician orders will be accurately interpreted and implemented."

Policy 15.00 titled "Medication Orders and Administration" dated reviewed 10/16 documented the following: Purpose- To provide standard operating procedures for administrating medications. Policy- It is the policy of (name of hospital) that nursing staff is responsible for proper administration of medications to support patient safety. . .10. If medication is not given for any reason, the reason and time shall be documented in the record. . .Documenting Medication Administration. . .D. The nurse administering medications is to initial and circle the initials of any scheduled medications that are not given or are refused by the patient and document in the patient's progress note reason for missed medication. . .Verification of Physician Orders/MAR (medication Administration record) Reconciliation by Midnight Staff. . .E. The midnight nurse will note any MAR variances for nursing leadership on the day shift. . ."

Based on observation, interview and record review, the facility failed to ensure medications were discarded when expired and the facility failed to ensure multi-dose medication vials and vaccines were labeled and dated when opened on 2 (SIPU and Adult) of 4 nursing units, resulting in the potential for medication inefficacy and ineffective medications being administered to all patients served. Findings include:

On 12/11/17 at 0940 an observation of the medication room on the Adult nursing unit was conducted with Licensed Practical Nurse (LPN) Staff J and the following was observed in the medication room refrigerator.
1. A vial of opened undated multi-dose Ativan (medication used for anxiety).
2. A vial of opened undated multi-dose tuberculin vaccine (PPD) (used for screening for tuberculosis).

At that time Staff J was asked to explain when both vials had been opened. Staff J said "I don't know. I didn't open them." She said "we use a lot of Ativan. We don't have to date when we open them (Ativan)." Staff J said "we only use the PPD for staff."

On 12/13/17 at 1135 an interview with the Director of Nursing Staff D, and a phone interview via speaker-phone was conducted with the Consultant Pharmacist Staff U. When queried regarding if opened multi-dose medication vials were required to be labeled and dated when opened Staff U was overheard as he explained multi-dose vials of injectables were only good for 28 days such as Insulin. However, Staff U was overheard as he said both vials should have been labeled and dated when opened and discarded by the labeled expiration date.

On 12/13/17 at 1145 when queried regarding the aforementioned concerns Staff D stated, "No, the nurse was wrong. All injectables have to labeled and dated when opened."

A review of the facility's "Medication Safety Plan/Policy" Number 7.000, dated 10/2016 documented:
"IV...g. All opened multi-dose (parental injection) vials shall be labeled with an expiration date that is no greater than 30 days from the dated first opened. Exception: All open Insulin vials will be labeled with an expiration date that is no greater than 28 days from the date first opened. (NOTE: unless the manufacturer's expiration date occurs prior to the 28 or 30 day expiration dates)."



28539

On 12/11/17 at 1020, during tour of the medication room in the autism unit (SIPU), with the registered nurse (RN G) present, an opened multi-dose container of oral liquid Acetaminophen (pain/fever reducing medication) 160 milligrams per every 5 milliliters was observed marked with an manufacturers expiration date of 09/19/17. The liquid Acetaminophen was stored in a cabinet with other medications, including medications prescribed to current patients.

During an interview with RN G on 12/11/17 at 1021, RN G said expired drugs were supposed to be placed into a designated box for return back to the pharmacy. RN G could not answer why the liquid Acetaminophen had not been returned to the pharmacy.

On 12/13/17 at 0815, a review was completed of the facility policy titled, "Medication Safety Plan/Policy". This policy indicated a last review date of October 2016. This policy indicated, under section "VI. Returned Medications", "All unused or expired medications dispense by the pharmacy shall be returned to the pharmacy for proper handling according to Pharmacy Law."

Based on interview and record review, the facility failed to provide two doctors of medicine or osteopathy within the composition of their internal utilization review committee placing all patients requiring utilization review services at risk for poor clinical outcomes. Findings include:

During an interview with the Director of Clinical Services (Staff E) on 12/12/17 at 0930, Staff E said the utilization review committee consisted of institutional staff, however, only one person on the committee was a doctor of medicine or osteopathy. Staff E indicated institutional staff were invited to the meetings via email and that meeting timeframe's had already been established.

On 12/12/17 at 0945 a review was completed of a facility email dated 04/20/17 at 1132. This email clarified utilization review committee meeting timeframe's effective "5/1/17". This email was addressed to eleven institutional employees, however, none of these employees was a doctor of medicine or osteopathy.

On 12/13/17 at 0825, a review was completed of the facility policy titled, "UR Committee Meeting". This policy was last revised on 06/01/17. This policy indicated, " ...each Medicare facility will employ a Utilization Management Committee ..." and, under procedures section, "2. The UM Committee should be compromised of at least two physicians ..."

Based upon observation, record review, and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:

See the individually and below cited K-tags dated December 13, 2017.
Building 01
K-0232
K-0353
K-0355
K-0363
K-0372
K-0374

Building 02
K-0223
K-0321
K-0353
K-0363
K-0920

Building 03
K-0232
K-0363
K-0372

Based on interview and record review the facility failed to provide anti-seizure medication and/or prescriptions upon discharge for one (#6) of 34 sampled patients reviewed for discharge planning form a total sample of 36, resulting in the potential for disruption of medication and risk of seizures. Findings include:

On 12/11/17 from approximately 0920 to 1100 a tour was conducted of the adult and older adult units of the facility. During the tour patient #6's Psychiatrist (Staff L) requested to speak to survey staff at 1010. During the interview Staff L was queried regarding orders for medications at discharge and stated medications needed after discharge would be ordered or prescriptions given at discharge. When queried about medications for seizures started during the patients stay at the hospital Staff L stated he or the medical doctor would order the medication at discharge.

On 12/12/17 beginning at 0900 review of the clinical record for patient #6 revealed an admission on 8/15/17 and discharge on 8/22/17. The initial nurse assessment dated 8/15/17 at 0100 noted patient reported becoming very angry after having seizures. Patient reports last seizure was 7/24/17. Further review of the clinical record revealed a physician order signed by a facility medical physician on 8/15/17 for Keppra (anti-seizure medication) 500 mg (milligrams) one by mouth every day for three days then twice a day for diagnosis of seizure.

Further review of the clinical record revealed a form titled "Discharge Care Plan and Home Medications" that documented "Current Medications-Discharge Medications with dosage changes." The form documented the medication, name, reason, dose, schedule and quantity. The following was listed: Trazadone for sleep, 150 mg (milligram)at bedtime, quantity 30, Lithium for mood, 300 mg, 3 tabs at bedtime, quantity 90, and Prozac for depression 20 mg, one daily, quantity 30- (all three are anti-depression medications) and Keppra (anti-seizure medications) for seizures, 500 mg, twice daily, a line was drawn in the column marked quantity (indicating none was given). The record included a prescription dated 8/21/17 for the three anti-depression medications as ordered above and included no refills. No prescription for Keppra was found in the clinical record.

On 12/13/17 at 1040 patient #6's Psychiatrist, Staff L was queried regarding patient #6 being discharged without a prescription for Keppra. Staff L looked at the order for Keppra dated 8/15/17 and stated that the facilities medical doctor had ordered the Keppra and that the internist would order that for discharge.

On 12/13/17 at 1053 the facility Director of Nursing (DON), Staff D was queried regarding the discharge plan and continuity of care for medications at discharge. Staff D reviewed patient #6's clinical record and stated "It looks like it was missed. She should have been given a prescription for the Keppra to go home."

On 12/13/17 at 1115 the facility Director of Clinical services and Discharge Planner, Staff D was interviewed regarding the discharge process. Staff D stated at discharge the patients Psychiatrist and the Registered Nurse discuss the medications and provide the medications or prescriptions at the time of discharge. Staff D stated the Physiatrist would contact the hospital internist for any questions or prescriptions for medical medications and the internist would order them at discharge.

On 12/13/17 at 1730 the facility policies related to discharge planning and medication safety were reviewed. The facility policy 7.000 titled "Medication Safety Plan/Policy" dated revised 10/2016 documented the following: "Policy-It is the policy of (hospital name) that physician orders will be accurately interpreted and implemented. . .M. Discharge Medication Orders: Discharge medication orders are directed at medications to be utilized post discharge."

Policy 2.09.00 titled "Discharge Planning" dated revised 8/2015, documented the following: "Purpose- To provide standard operating procedures for the staff to assure a smooth transition for the patient upon discharge. Policy. . .Aftercare treatment and residential needs will be incorporated into the discharge planning process. . .E) RN: 1. Verify physician orders. . .3 Review medications and be sure that all prescriptions and/or medications are ready, i.e., sent to pharmacy, back from pharmacy, correct, etc."

Based on interview and record review, the facility failed to assure that patients in one (1) of five (5) certified units (Co-Occurring Disorders) were under the care of a psychiatrist, either directly or via on-going supervision. Instead this 24-bed program with 18 patients on the first day of the survey (1/3/18) was under the care of a Doctor of Internal Medicine who was also boarded in Addiction Medicine. This practice compromises the facility's ability to ensure that the direct involvement of a psychiatrist is involved in the care and treatment of these patients' major psychiatric disorders. (Refer to B99)

Based on interview and record review, the facility failed to ensure that the care of patients in one patients in one (1) of five (5) certified units (Co-Occurring Disorders) was directed, directly or via on-going supervision, by a psychiatrist. The admission, treatment and discharge of these patients were provided and directed by a Doctor of Internal Medicine who has specialized in Addiction Medicine (Physician 1). Services offered by a psychiatrist for patients on this unit are by consultation only. This practice compromises the facility's ability to ensure that the direct involvement of a psychiatrist is involved in the care and treatment of these patients' major psychiatric disorders.

Findings include:

A. Program Description:

The Co-Occurring Disorders Unit is a co-ed 24-bed unit for adults with a patient census of 18 on the first day of the survey. Review of a program description, Harbor Oaks Hospital Co-Occurring Disorders Unit (undated), provided by the Chief Executive Officer revealed a description of Detoxification Services and Rehabilitation Services. This written description failed to specifically address the evaluation and treatment of severe psychiatric disorders, including the psychiatrist role in the evaluation and treatment of the patients.

B. Interview:

1. During the opening conference on 1/3/18 at 9:45 a.m., the CEO and Director of Quality and Risk Management reported that the facility has a Chemical Dependency Unit (Co-Occurring Disorders). The care and treatment of the patients on this unit is directed by a Doctor of Internal Medicine who was also boarded in Addiction Medicine (Physician 1). The CEO reported that there was not a psychiatrist assigned to the on-going care of the patients on this unit, but that these patients were seen by a psychiatrist for issues such as medication based on a consultation request.

2. During interview on 1/4/18 at 9:00 a.m., the Chief Medical Officer reported that the two medical physicians are credentialed to treat and care for patients with chemical dependency issues. He stated, "I defer to these guys (Internal Medicine physicians) as addiction is their specialty." He stated that he consults with patients on that unit (on psychiatric issues). He stated that he is more involved with the Chemical Dependency Unit (Co-Occurring Disorders) when there are problems such as conducting a "root cause analysis" or to give input regarding regulatory oversight. The Chief Medical Officer verified that he was not involved with the specific treatment of the patients on the Chemical Dependency Unit (Co-Occurring Disorders) including their psychotropic medications unless he was called to conduct a consultation.

3. During telephone interview on 1/4/18 at 11:00 a.m., Physician 1 (Internal Medicine Director of the Chemical Dependency Unit) stated, "I am the Director of the Chemical Dependency and Co-Occurring Disorder Unit. He reported that he does see the Chief Medical Officer about patient care on the unit on a regular basis. He added, "We meet in the hallway or I see him in the nursing station. He has my cell number and I have his." I refer patients from the unit to him for psychiatric consults for "break through issues related to substantial compliance with treatment."

4. During interview on 1/4/18 at 2:30 p.m., the CEO reported that previously there was on-going patient consultation provided by a psychiatrist for the Chemical Dependency Unit. She stated that after this physician went out on medical leave another psychiatrist had not been assigned to this unit. She stated that the original name of this unit was the Co-Occurring Disorders Unit.

C. Review of Physician 1's Curriculum Vitae revealed that he has been awarded a degree of Doctor of Medicine in the category of Internal Medicine. In addition, he is a Board Certified Diplomate of the American Boards of Internal Medicine and Addiction Medicine.

Based on interview and record review the facility failed to:

I. Ensure that the care of patients in one (1) of five (5) certified units (Co-Occurring Disorders) is directed, directly or via on-going supervision, by a psychiatrist. The admission, treatment and discharge of these patients are provided and directed by a Doctor of Internal Medicine who has specialized in Addiction Medicine (Physician 1). Services offered by a psychiatrist for patients on this unit are by consultation only. This practice compromises the facility's ability to ensure that the direct involvement of a psychiatrist is involved in the care and treatment of these patients' major psychiatric disorders. (Refer to B99)

II. Ensure that the treatment of major psychiatric disorders are treated and documented for two (2) of two (2) active sample patients (B4 and B16) and two (2) of four (4) non-sample patients (B6 and B12) chosen from the census of 18 on the Co-Occurring Disorder Unit with a diagnosis of a major psychiatric disorder. Issues related to major psychiatric disorders and use of psychotropic medications was not clearly addressed by the treatment team for these patients. This failure hinders quality treatment for all patients with severe psychiatric disorders on this unit. (Refer to B125, Section II)

Based on interview and record review the specific treatment recommendations defining the anticipated social work role in the treatment and discharge of patients were not adequately documented for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1) in the psychosocial assessments. This failure hindered treatment and discharge planning for the patients.

Findings include:

A. Record Review

1. Patient A1-psychosocial assessment dated 12/27/17; did not identify specific roles for social work in this patient treatment.
The recommended role of social worker in the treatment and discharge of this patient was a generic function statement "We will also assist [Name of patient] with follow up care to continue receiving treatment to manage his/her symptoms." Unclear who "we" are/discipline, and what assistance will be given with follow up care.


2. Patient A2- psychosocial assessment dated 11/17/17; did not identify specific roles for social work in this patient treatment.

The recommended role of social worker in the treatment and discharge of this patient was a generic function statement "we will also assist him/her with follow up care to manage his/her outbursts. We will also coordinate placement with his/her outpatient team." No specific community resources/support systems for utilization in discharge planning were identified.

3. Recommended role of social worker in the treatment and discharge of following patients (dates of psychosocial in parenthesis): A3 (12/22/17), B4 (12/30/17) and B16 (12/29/17) was not addressed;

4. Patient C1- psychosocial assessment dated 8/20/17; did not identify specific roles for social work in this patient treatment.
The recommended role of social worker in the treatment and discharge of this patient was a generic function statement "continue to review patient's case in order to identify supports, housing, or outpatient provider in order to facilitate a safe discharge."

5. Patient D3---psychosocial assessment dated 12/31/17

The only recommendation for the role of social worker in the treatment and discharge of this patient was a generic function stated as "SW (Social Worker) will coordinate appropriate d/c (discharge) plan with aftercare services to the psychiatrist and case manager and complete group therapy with Pt., (Patient)."

6. Patient D10-psychosocial assessment dated as 12/17/17

A portion of the social work role recommendation was a generic role function stated as "SW will coordinate appropriate d/c (discharge) plan with aftercare services ...and ensure a safe d/c back to the pat's home."

9. Patient E1-psychosocial assessment dated 12/20/17

A portion of the social work role recommendation was a generic role function stated as "SW will coordinate appropriate d/c (discharge) plan with aftercare services ... and ensure a safe d/c back to the pt.'s home."

B. During interview, with review of above findings, on 1/4/18 at 11:40 a.m. the Director of Social Work verified above findings.

Based on record review and interview, there was failure to specifically address orientation, memory functioning and intellectual functioning for four (4) of nine (9) sample patients (A1, C1, D3 and D10). This failure hinders the treatment team's ability to determine stability or change in status in subsequent reassessment.

A. Record Review:

1. Patient A1- psychiatric evaluation dated 12/27/17

Recent memory function and concentration/attention span were not specifically addressed.
Recent memory function: "Within normal limits."
Concentration/Attention Span: "Within normal limits."

2. Patient C1 - psychiatric evaluation dated 10/6/17

Orientation and recent memory function were not specifically addressed.
Orientation: "Not tested."
Recent memory function: "Not tested."

3. Patient D3-psychiatric evaluation dated 12/30/17

Orientation and intellect were not specifically addressed. The only documentation for recent and remote memory findings was documented as "Intact."

4. Patient D10-psychiatric evaluation dated 12/17/17

Orientation and intellect were not specifically addressed. The only documentation for recent and remote memory findings was documented as "Within normal limits."

B. During interview on 1/4/18 at 9:00 a.m. the Chief Medical Officer stated that data for the mental status was listed to guide the physician in conducting the mental status. He stated, "It was left out" when discussing the documentation of memory intact in the mental status for some patients.

Based on record review and interview, there was failure to note patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1). This lack of patient information inhibits the physician's direction in formulating treatment plans utilizing patient strengths as a basis for treatment focus.

Findings include:

A. Record Review:

1. Patient A1- psychiatric evaluation dated 12/27/17

The only asset listed for this patient was stated as "He/she has housing." There was no personal skills or achievements listed for this patient.

2. Patient A2- psychiatric evaluation dated 11/17/17

The only asset listed for this patient was stated as "He/she has income."

3. Patient A3- psychiatric evaluation dated 12/21/17

The only asset listed for this patient was stated as "Grossly normal"

4. Patient B4-psychiatric evaluation dated 12/28/17

The only asset listed for this patient was stated as "The patient has taken the initiative with motivation, insight, and judgment to seek treatment for chemical dependency."

5. Patient B16-psychiatric evaluation dated 12/28/17

The only asset listed for this patient was stated as "The patient has taken the initiative with motivation, insight, and judgment to seek treatment for chemical dependency."

6. Patient C1- psychiatric evaluation dated 10/6/17

The only asset listed for this patient was stated as "Resources for treatment, treatment team invested in her well-being."

7. Patient D3-psychiatric evaluation dated 12/30/17

The only asset listed for this patient was stated as "Good physical health."

8. Patient D10-psychiatric evaluation dated 12/17/17

The only asset listed for this patient was stated as "[S/he] has good physical health and some insight into [his/her] illness."

There were no personal skills or achievements listed for the patients listed above.


9. Patient E1-psychiatric evaluation dated 12/20/17

Assets for this patient were not documented in the psychiatric evaluation.



B. During interview on 1/4/18 at 9:00 a.m. the Chief Medical Officer verified that some statements listed as patient assets in the psychiatric evaluations were not helpful (examples as supportive family, volunteered for treatment) in the development of the treatment plans.

Based on record review and interview, the Master Treatment Plans (MTPs), called Interdisciplinary Treatment Plan by the facility, for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1) failed to specify short-term goals stated in observable, measurable, patient behaviors to be achieved. Some of the listed goals were stated as staff expectations for the patient's participation in treatment rather than as behavioral outcomes for the patient to achieve; others were incorrectly stated as staff interventions. Because the objective statements on the MTP lacked individualized symptoms, specific descriptors, and observable behaviors, it was difficult to judge the effectiveness of treatment and to implement possible changes in treatment. These failures can hamper how clinical staff evaluated each patient changes or improvement based on information provided on treatment plans.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parenthesis): A1 (12/27/17, updated 1/2/18), A2 (11/17/17, updated 1/2/18), A3 (12/20/17, updated 1/3/18), B4 (12/30/17), B16 (12/29/17), C1 (8/21/17, updated 12/13/17), D3 ( 12/31/17), D10 ( 12/17/17, updated 12/28/17) and E1 ( 12/20/17, updated on 1/2/18 with a separate behavior plan-no date).

This review revealed the following deficient short-term goals (STG).

1. Patient A1: Problem statement: "Depressed Mood with Psychosis. Manifested by/as evidenced by [name of patient] was admitted to Harbor Oaks Hospital inpatient due to depressed mood with psychosis AEB (as evidenced by) SI (suicide ideation). Pt (patient) attempted to overdose on 60 + Ambien pills. Pt (patient) is non-compliant with psych (psychotropic) medications. Pt (patient) lacks insight judgement."

a. Short-term goal: "[Name of patient] will learn at least 3 new coping skills to help effectively manage her depressed mood with psychosis." Goal was staff expectation/treatment compliance statement rather than a measurable goal.

b. Short-term goal: "[Name of patient] will meet with assigned psychiatrist and nursing team on a daily basis to discuss and report a decrease in depressed mood with psychosis AEB (as evidenced by) SI (suicide ideation)." Goal was staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether patient stated problem was reduced/resolved. "Self-report" no identified method to determine whether patient was sharing his/her feelings, thus not a measurable goal.

2. Patient A2: Problem statement: "Anger/Aggression. Manifested by/as evidenced by [Name of patient] presented to the ER (Emergency Room) with aggressive behavior, threw his/her meds (medications) down the drain, multiple fights in the past group home and property damage."

a. Short-term goal: "[Name of patient] will meet with assigned psychiatrist daily, comply with meds, and report decrease in anger/aggression for 4 consecutive days." Goal was staff intervention/expectation and failed to give focus to specific treatment of identified problem.

b. Short-term goal: "[Name of patient] will display 2-3 self-soothing techniques to manage mood/anger by d/c (discharge) date." Goal was not specific, what "self-soothing techniques" patient would be using/learned/taught to "manage mood/anger" "discharged date" was not identified, failed to be written in behavioral terms and were mostly staff expectations of the patient instead of patient outcomes related to addressing the identified problem/give focus to specific treatment of identified problem.

3. Patient A3: Problem statement: "Manic Mood. Manifested by/as evidenced by [Name of patient] presents to the Harbor Oaks with psychosis, delusional thinking. Pt (patient)t verbalized suicidal and homicidal threats. Pt (patient) further presents with religious preoccupation."

a. Short-term goal: "[Name of patient] will attend groups daily for self-esteem, identifying multiple coping strengths when experiencing symptoms, and (+) (positive) supports to utilize." Goal was written as a compliance statement/staff expectations of the patient instead of patient outcomes related to what the patient would be doing or saying to demonstrate improvement of the identified problem. Unclear what behaviors would be considered as "coping strengths", how would staff know when patient was experiencing "symptoms" and who/what would be identified as "positive supports to utilize."

b. Short-term goal: "[Name of patient] will meet with physician daily and comply with medication prescribed in an effort to balance mood and alleviate symptoms accompanied with manic and psychosis. Further notify psychiatry team if increase or decrease in symptoms." Goal was a treatment compliance statement /not measurable/individualized. Staff expectation and failed to give focus to specific treatment of identified problem.

4. Patient B4: Problem statement: Alcohol Dependence as evidenced by "[Patient] reports consuming approximately ½ pt. (pint) of alcohol daily ..."

a. The long term goal was a non-measurable statement: "[Patient] will establish sobriety and develop coping skills for dealing with dealing with (sic) health issues."

b. Short term goals were stated as "[Patient] will attend psychotherapy groups daily to develop coping skills for dealing with physical and mental health issues" and "[Patient] will comply with detox protocol and develop a health medication regimen to eliminate self-medicating." The first part of these statements was treatment compliance expectations; the last parts were non-measurable.

5. Patient B16: Problem statement: Opioid Use Disorder as evidenced by "[Patient] reported 1 gram of heroin daily."

a. The long term goal was a non-measurable statement: "[Patient] will establish sobriety and develop coping skills for living sober."

b. Short term goals were stated as "[Patient] will attend psychotherapy groups daily to develop coping skills to learn how to process and accept [his/her] emotions and to handle stress" and
"[Patient] will comply with detox protocol and develop a health medication regimen to eliminate self-medicating." The first part of these statements was treatment compliance expectations; the last parts were non-measurable.

6. Patient C1: Problem statement: "Disturbed Thought. Manifested by/as evidenced by [Name of patient] presented to ER (Emergency Room) with increase agitation and aggression towards staff at the group home. Pt (patient) was also verbally aggressive to group home residents."

a. Short-term goal: "[Name of patient] will meet with attending physician daily and report decrease in aggression for 4 consecutive days." Goal described routine discipline function/staff expectation/treatment compliance which does not define patient improvement and a measurable goal. There was no way to determine whether patient was self-reporting his/her "decrease in aggression."

b. Short-term goal: "[Name of patient] will verbalize 2-3 coping strategies to manage anger and frustration by d/c (discharge) date." Goal was not written in behavioral terms/measurable. Written as staff expectation of the patient instead of patient outcomes related to what patient would be demonstrating to show improvement of the identified problem. "2-3 coping strategies" not identified what specific coping strategies would be used "to manage anger and frustration."

7. Patient D3: Problem statement: "Depressed mood without psychosis as evidenced by [Patient] presents from Safhaus for not obeying the rules, not taking medications, and destroying property. [S/he] has prior SI (Suicide Ideation) attempts from putting bag over [his/her] head and attempting to jump out a bus window."


a. The long term goal was a non-measurable statement: "[Patient] will stabilize crisis situation of depression and SI through the use of health and safe methods of coping with depressed behaviors and impulses that interfere with positive lifestyle and ability to function in society."

b. A non-measurable short term goal was stated as "[Patient] will attend groups daily for purposes of self-reflection, identifying 10 or more coping strategies when experiencing symptoms of depression ..."

c. A short term goal was stated as "[Patient] will comply with medication regimen as prescribed by psychiatrist in an effort to balance mood, eliminate depression, and alleviate symptoms of sadness ..." This is a statement of treatment compliance.

8. Patient D10: Problem statement: "Depressed mood without psychosis as evidenced by[Patient] presents as depressed with self-injurious behaviors, aeb: cutting [himself/herself] on both arms. The pt. (patient) has a history of suicide attempts."

a. The long term goal was a non-measurable statement: "[Patient] will alleviate suicidal ideation and depressive thought patterns. [s/he] will improve stabilization in [his/her] mood and behavior prior to discharge."

b. A non-measurable short-term goal was stated as "[Patient] will work to decrease the frequency of depressed mood with SI (Suicide Ideations) ..."

c. A short term goal stated as treatment compliance was "[Patient] will cooperate and take medications as ordered."

9. Patient E1: Problem statement: "Impulsivity as evidenced by [Patient] became agitated during school and banged [his/her] head through a glass pane. Pt. (Patient) continued to assault [his/her] teacher and student peers ...Pt. will hit [himself/herself] in the face, kick walls, and pick [his/her] scabs until they bleed."

a. The long term goal was a non-measurable statement: "[Patient] will lean (sic) ways to manage [his/her] anger." Another part of the long term goal was a treatment compliance statement: "Pt will take all medication as prescribed."

b. A short term goal was stated as a treatment compliance statement: "[Patient] will comply with medication regimen."

B. Policy Review

A review of the facility's policy titled, "Individualized Plan of Service (IPOS)/Treatment Planning, Policy # 2.21.00." reviewed, 10/2015 states: "The plan shall establish specific, measurable objectives and methods for their achievement." The facility fails to follow its own requirements for writing objectives.

C. Interviews

1. An interview on 1/3/18 at 2:10 p.m., with Charge Nurse RN 1, she concurred that the goals and interventions needed to be specific to the identified problems and that they were not measurable and observable.

2. In an interview on 1/3/18 at 4:00 p.m., with Charge Nurse RN 2, she stated "I agree with you, we need to be more specific."

3. In an interview with the Nursing Director on 1/4/18 at 1:30 p.m., the Treatment Plans were review. The Nursing Director acknowledged that the Treatment plans goals and interventions need to be more individualized and written in observable and measurable terminology.

4. In an interview with the unit Social Workers on 1/4/18 at 11:25 a.m., they agreed that the goals were not written in observable, measurable patient behaviors to be achieved.

Based on observation, record review and interview, the facility failed to develop Master Treatment Plans (MTP's) that evidenced planning of interventions with specific focus based on individual needs and abilities for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1). The interventions listed on the plans included routine clinical functions that were required for all patients regardless of their assessed needs, reason for admission or continued hospitalization. The MTPs of some sample patients failed to state whether interventions would be delivered in group or individual sessions. These deficiencies result in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment, and failed to provide guidance to staff regarding the specific interventions and the purpose for each. This failure also potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Patient A1: MTP dated 12/27/17 and updated 1/2/18 identified the Problem as "Depressed Mood with Psychosis. Manifested by/as evidenced by [name of patient] was admitted to Harbor Oaks Hospital inpatient due to depressed mood with psychosis AEB (as evidenced by) SI (suicide ideation). Pt (patient) attempted to overdose on 60 + Ambien pills. Pt (patient) is non-compliant with psych (psychotropic) medications. Pt (patient) lacks insight judgement."

Deficient intervention statements listed on the MTP were as follows:

a. Physician: "Will meet with [Name of patient] daily to assess treatment effectiveness and adjust medication as needed." Intervention was generic and routine discipline functions and failed to identify a method of delivery (group or individual sessions).

b. Nursing: "Assess [Name of patient] for symptoms of depression, provide support and education on medication." Intervention was generic and routine discipline functions and failed to identify a method of delivery (group or individual sessions). Failure to identify name of medication and content of what would be taught.

c. Social Work: "Provide daily DBT (Dialectical Behavior Therapy) group to assist with development of coping skills to help manage depressed mood and psychosis." Intervention did not identify which (DBT) treatment strategy would be utilized and which coping skills would be developed/taught.
d. Activity Therapy/Recreational Therapy: "Encourage [Name of patient] to attend daily leisure group and 1:1 to identify healthy alternatives for decreasing depressed mood." Intervention did not identify what alternatives would be the focus of the group "for decreasing depressed mood."

2. Patient A2: MTP dated 11/17/17 and updated 1/2/18 identified the Problem as "Anger/Aggression. Manifested by/as evidenced by [Name of patient] presented to the ER (Emergency Room) with aggressive behavior, threw his/her meds (medications) down the drain, multiple fights in the past group home and property damage."

Deficient intervention statements listed on the MTP were as follows:

a. Physician: No interventions documented.

b. Nursing: No interventions documented.

c. Social Work: "Will provide daily group to assist patient with identifying anger management skills to regulate and maintain stabilization." Intervention did not identify which anger management skills would be identified and how would it be applied/used to "regulate and maintain stabilization."

d. Activity Therapy/Recreational Therapy: "Facilitate daily group and 1:1 to assist [Name of patient] in identifying healthy alternatives for aggressive behavior." Intervention lacked what healthy alternatives would be presented/method utilized in identifying "healthy alternatives for aggressive behavior."

3. Patient A3: MTP dated 12/20/17 and updated 1/3/18 identified the Problem as "Manic Mood. Manifested by/as evidenced by [Name of patient] presents to the Harbor Oaks with psychosis, delusional thinking. Pt (patient) verbalized suicidal and homicidal threats. Pt (patient) further presents with religious preoccupation."

Deficient intervention statements listed on the MTP were as follows:

a. Physician: "Will meet with [Name of patient] daily to assess treatment effectiveness and adjust medication as needed for symptom management." Intervention was generic and routine discipline functions and failed to identify a method of delivery (group or individual sessions).

b. Nursing: "Assess [Name of patient] for symptoms of psychosis, and provide support and education on medication compliance." Intervention was generic and routine discipline functions and failed to identify a method of delivery (group or individual sessions). Failure to identify name of medication and content of what would be taught.

c. Social Work: "Encourage [Name of patient] to participate in 1:1 and group therapy to identify skills and supports to cope." Intervention failed to identify name of group, skills to be taught and what supports were available to help patient "cope."
d. Activity Therapy/Recreational Therapy: "Facilitate daily activity and leisure group to assist [Name of patient] in identifying healthy alternatives for increasing reality." Intervention did not identify what leisure group and method to be used in "identifying healthy alternatives."

4. Patient B4: MPT dated 12/30/17. Problem statement: "Alcohol Dependence as evidenced by [Patient] reports consuming approximately ½ pt. (pint) of alcohol daily ..."

Deficient intervention statements listed on the MTP were as follows: There was no physician or nursing interventions on this plan.

5. Patient B16: MPT dated 12/29/17. Problem statement: "Opioid Use Disorder as evidenced by [Patient] reported 1 gram of heroin daily."

Deficient intervention statements listed on the MTP were as follows: There was no physician or nursing interventions on this plan.

6. Patient C1: MTP dated 8/21/17 and updated 12/13/18 identified the Problem as "Disturbed Thought. Manifested by/as evidenced by [Name of patient] presented to ER (Emergency Room) with increase agitation and aggression towards staff at the group home. Pt (patient) was also verbally aggressive to group home residents."

Deficient intervention statements listed on the MTP were as follows:

a. Physician: No interventions documented.

b. Nursing: "Confer with patient to discuss benefits and side effects of prescribed medications." Intervention was generic and routine discipline functions and failed to identify a method of delivery (group or individual sessions) and name of prescribed medications.

c. Social Work: "Provide group support to assist patient with developing structure to manage mood." Intervention failed to identify name of group, method used for developing "structure to manage mood." and how it would be applied.

d. Activity Therapy/Recreational Therapy: "Provide [name of patient] with daily leisure group and 1:1 to assist in identifying strategies for self-care and depressed thought." Intervention did not identify name of group, method utilized in identifying "strategies for self-care" and how it would be implemented/utilized.

7. Patient D3: MPT dated 12/31/17. Problem statement: "Depressed mood without psychosis as evidenced by [Patient] presents from Safhaus(sic-safe house]) for not obeying the rules, not taking medications, and destroying property. [S/he] has prior SI (Suicide Ideation) attempts from putting bag over [his/her] head and attempting to jump out a bus window."

Deficient intervention statements listed on the MTP were as follows:

a. There were no physician interventions on this MTP.

b. There were no nursing interventions on this form. Even though this patient was admitted with suicide attempts, there were no safety nursing interventions to care for this patient in the clinical area. In addition, even though this patient had not been compliance with prescribed medications, there were not nursing interventions to address this issue.

8. Patient D10: MTP dated 12/17/17 with update on 12/28/17. Problem statement: "Depressed mood without psychosis as evidenced by[Patient] presents as depressed with self-injurious behaviors, aeb: cutting [himself/herself] on both arms. The pt. (patient) has a history of suicide attempts.

Deficient intervention statements listed on the MTP were as follows:

a. A role function statement was listed as the only physician intervention: "Meet c/ (with) [Patient] daily to assess treatment effectiveness and adjust medication as needed for symptom management."

b. A role function statement was listed as a nursing intervention: "Assess [Patient] for symptoms of depression and provide support and redirection as needed. Even though this patient was admitted with self-injurious behaviors and previous suicide attempts, there were no safety nursing interventions to care for this patient in the clinical area.

9. Patient E1: MTP dated 12/20/17, updated on 1/2/18 with a separate behavior plan-not dated. Problem statement: "Impulsivity as evidenced by [Patient] became agitated during school and banged [his/her] head through a glass pane. Pt. (Patient) continued to assault [his/her] teacher and student peers ...Pt. will hit [himself/herself] in the face, kick walls, and pick [his/her] scabs until they bleed."

Deficient intervention statements listed on the MTP were as follows:

a. There was no physician intervention on this treatment plan.

b. There were no specific nursing interventions to address this patient's safety issues.

c. Even though there was a behavioral plan to address this patients safety issues, this plan was not integrated with or cross=referenced to the patient's master treatment plan. The plan was not given to the surveyor with the Interdisciplinary Treatment Plan, but instead was provided upon request.

B. Interviews:

1. During interview on 1/4/18 at 9:00 a.m. the Chief Medical Officer agreed the physician intervention on Patient D10's treatment plan was a general statement, rather than specific to this patient.

2. In an interview on 1/3/18 at 2:10 p.m., with Charge Nurse RN 1, she concurred that the goals and interventions needed to be specific to the identified problems and that they were not measurable and observable.

Based on interview and record review the facility failed to ensure that the care of patients in one (1) of five (5) certified units (Co-Occurring Disorders) was evaluated, directly or via on-going supervision, by a psychiatrist. The admission, treatment and discharge of these patients are provided and directed by a Doctor of Internal Medicine who has specialized in Addiction Medicine (Physician 1). Services offered by a psychiatrist for the patients on this unit are by consultation only. This practice compromises the facility's ability to ensure that the direct involvement of a psychiatrist is involved in the care and treatment of these patients' major psychiatric disorders. (Refer to B99)

In addition, the facility failed to ensure that the treatment of major psychiatric disorders are treated and documented for two (2) of two (2) active sample patients (B4 and B16) and two (2) of four (4) non-sample patients (B6 and B12) chosen from the census of 18 on the Co-Occurring Disorder Unit with a diagnosis of a major psychiatric disorder. Issues related to major psychiatric disorders and use of psychotropic medication was not clearly addressed by the treatment team for these patients. This failure hinders quality treatment for all patients with severe psychiatric disorders on this unit.

Findings include:

A. Patient Findings:

1. Patient B4 was admitted on 12/28/17 to the Co-Occurring Disorders Unit. The psychiatric evaluation/admission note (12/28/17) documented this patient's admission diagnoses as opiate dependency, uncomplicated and polysubstance abuse.

This patient's medication, Seroquel 300 mg daily, was continued upon admission to the facility. Even though s/he was not given a major psychiatric diagnosis, the patient remained on this medication during hospitalization. In addition, reason for this medication was not addressed in Patient B4's Treatment Plan dated 12/30/17.

2. Patient B6 was admitted on 12/29/17 to the Chemical Dependency Unit. The psychiatric evaluation/admission note (12/30/17) documented this patient's admission diagnoses as alcohol dependency with withdrawal uncomplicated, opiate dependency with withdrawal and major depressive disorder. This patient was not placed on any medications for the major depressive disorder. There was no documentation regarding the current standing of this disorder, or was there documentation regarding why medication was not needed for this patient's depressive disorder. In addition, this disorder was not addressed in his/her Treatment Plan dated 12/31/17.

3. Patient B12 was admitted on 12/27/17 to the Chemical Dependency Unit. The psychiatric evaluation/admission note (12/28/17) documented this patient's admission diagnoses as alcohol dependency with withdrawal mild uncomplicated, schizoaffective disorder depressed type, generalized anxiety disorder. Upon admission, Patient B12's medication, Seroquel 400 mg PO BID (by mouth twice daily), was continued. Even though this patient was on medication for this severe psychiatric disorder, related issues were not addressed in his/her Treatment Plan dated 12/28/17.

4. Patient B16 was admitted on 12/28/17 to the Chemical Dependency Unit. The psychiatric evaluation/admission note (12/28/17) documented this patient's admission diagnoses as opiate dependency, cocaine dependency, and major depressive disorder with possible bipolar disorder. Upon admission, Patient B16's medications, Doxepin HCL 100 mg QHS (every night), Quetapine 100 mg QAM (every morning), and Divalproex 500 mg 2 tabs QHS, were continued. Even though this patient was on medication for this severe psychiatric disorder, related issues were not addressed in his/her Treatment Plan dated 12/29/17.

B. During interview on 1/4/18 at 9:00 a.m. the Chief Medical Officer verified that the patients on this unit were diagnosed and treated for major psychiatric disorders. He reported that when the medical internists have a question, the patient is referred to him for a consultation.

Based on interview and record review the Chief Medical Officer (Clinical Director) failed to:


I. Ensure that patients in one (1) of five (5) certified units (Co-Occurring Disorders) are under the care of a psychiatrist, either directly or via on-going supervision. Instead this 24-bed program with 18 patients on the first day of the survey (1/3/18) was under the care of a Doctor of Internal Medicine who is also boarded in Addiction Medicine. This practice compromises the facility's ability to ensure that the direct involvement of a psychiatrist is involved in the care and treatment of these patients' major psychiatric disorders. (Refer to B99)

II. Ensure that the treatment of major psychiatric disorders were treated and documented for two (2) of two (2) active sample patients (B4 and B16) and two (2) of four (4) non-sample patients (B6 and B12) chosen from the census of 18 on the Co-Occurring Disorder Unit with a diagnosis of a major psychiatric disorder. Issues related to major psychiatric disorders and use of psychotropic medications was not clearly addressed by the treatment team for these patients. This failure hinders quality treatment for all patients with severe psychiatric disorders on this unit. (Refer to B125, Section II)

III. Ensure that patient assets in the psychiatric assessment were listed in descriptive, not interpretive, fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1). This lack of patient information inhibits the physician's direction in formulating treatment plans utilizing patient strengths as a basis for treatment focus. (Refer to B116)

IV. Ensure that Interdisciplinary Treatment Plans for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1) included long and short term goals stated in observable outcome patient behaviors to be achieved (B121) and interventions with specific focus based on individual needs and abilities (B122). These failures can hamper how clinical staff evaluated each patient's changes or improvement and to provide guidance to staff regarding the specific interventions and the purpose for each.

Based on observation, record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. The identified short-term goals in MTPs and Treatment Plan Updates for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1) were written in observable, measurable patient behavior to be achieved and addressed the individual patient presenting problems and needs (Refer to B121).

II. Active treatment interventions implemented by Registered Nurses for nine (9) of nine (9) active sample patients (A1, A2, A3, B4, B16, C1, D3, D10 and E1) were not linked to specific treatment goals. The listed nursing intervention was routine, generic discipline functions expected to be regularly provided by nursing staff for all patients and was generic in nature such as, "assess for symptoms," "provide support," "confer with patient to discuss benefits and side effects of prescribed medication." Interventions were also written as staff expectations/compliance statements. These failures to develop focused, individualized interventions can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122).

A. Staff Interview

In an interview with the Nursing Director on 1/4/18 at 1:30 p.m., the Treatment Plans were reviewed. She acknowledged that the treatment plans goals were not written in observable and measurable patient behaviors to be achieved. She did not dispute the finding that nursing interventions were generic and routine nursing functions.