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Based on a review facility documentation, of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the "Important Message from Medicare (IM)" for four of four Medicare medical records reviewed (MR20, MR21, MR22, and MR23).

Findings include:

A review on June 10, 2015, of the Philhaven Hospital admission policy 4600.001 last reviewed October 26, 2011, revealed, " ...For those patient with Medicare, the Medicare " Message " will be explained to the patient with a signed copy going to the chart and another copy offered to the client. ... . " The policy did not address notification two days before the patient discharge from the hospital.

A review on June 10, 2015, of MR20, MR21, MR22, and MR23 revealed there was no signed copy of the Important Message from Medicare contained in the medical records on admission and prior to discharge.

An interview conducted on June 10, 2015, at 10:30 AM with EMP3 confirmed the medical records did not have the required copy of the "Important Message From Medicare."

Based on review of medical records and interview with staff (EMP), it determined that the facility failed to have a system in place to ensure that a patient's family and primary care physician was contacted as soon as possible after the patient was admitted for seven of 10 medical records reviewed (MR14, MR16, MR19, MR20, MR21, MR22 and MR23).

Findings include:

A review on June 9, 2015, of MR14, MR16, MR19, MR20, MR21, MR22 and MR23 revealed no documentation contained in the medical record that the patient's primary care physician and /or family was notified as soon possible after the patient was admitted to the hospital.

An interview conducted on June 9, 2015, at 10:50 AM with EMP1 confirmed that MR14, MR16, MR19, MR20, MR21, MR22 and MR23 did not contain documentation that the facility asked the patient if the patient wanted their physician to be contacted. Further interview with EMP1 confirmed that there was no policy that addressed notification of primary care physician and family member at time of admission.

Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the patient's care plan was modified for the use of seclusion for three of four restraint records reviewed (MR9, MR10, and MR12).

Findings include:

A review on June 9, 2015, of facility policy "Seclusion/Restraints", effective date 04/17/15, revealed, "...Documentation: ... e. A Treatment Plan will be initiated or updates after each seclusion..."

A review on June 9, 2015, of MR9, MR10, and MR12 revealed nursing documentation that the patient were in seclusion. Further review revealed the patient's plan of care was not modified for the use of seclusion.

An interview conducted on June 9, 2015, at 3:10 PM with EMP1 and EMP2 confirmed that the patients was in seclusion and there was no modification to the plan of care with regard to seclusion use.

Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the seclusion order was time limited for the use of seclusion for two of four restraint records reviewed (MR9, and MR12).

Findings include:

A review on June 9, 2015, of facility policy "Seclusion/Restraints", effective date 04/17/15, revealed "...B. Procedure: ...4. Written or verbal orders for initial and continuing seclusion are time - limited and include: a. Appropriate time limits: 1) Adults(18 years and up), not to exceed 4 hours. (2) Children and Adolescents, not to exceed 1 hour..."

A review of MR9 and MR12 revealed nursing documentation that the patient were in seclusion and the order was not time-limited.

An interview conducted on June 9, 2015, at 3:10 PM with EMP1 and EMP2 confirmed that the patients was in seclusion and the order was not time-limited.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure problems identified in the Infection Control program and medical staff performance improvement program were addressed in the hospital's Quality Assurance Performance Improvement program.

Findings include:

A review on June 10, 2015, of the facility's "Performance Improvement Plan(PI)," effective April 8, 2015, revealed "Purpose: A. To provide an organizational structure that promotes continuously improving performance in the context of (name redacted ) strategic vision, mission, values, priorities and goals... II Policy ...C. All disciplines, programs, services, and support systems will collaborate as needed to achieve PI goals ...Procedures ...5. The Board of Directors will establish a PI Committee of the Board, which will review regular summary reports presented by the Director of PI and other staff as appropriate ...D. Director of Performance Improvement, or DOPI. 1. The DOPI, under the direction of the CEO, will take primary responsibility for implementing the PI Plan ... "

A review of the Quality Committee Meeting Minutes revealed no documentation of infection control or medical staff performance improvement program was addressed in the hospital ' s Quality Committee meetings.

An interview conducted on June 9, 2015 with EMP3 revealed that infection control or medical staff performance improvement program were not addressed in the hospital ' s Quality Committee meetings. Further interview revealed that infection control or medical staff performance improvement program are reviewed by the Governing Body but is not reviewed by the Quality Committee..."

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the Director of Food Service failed to ensure safety practices for food handling were maintained in the kitchen.
Findings include:
A review on June 8, 2015, of facility policy "Supplies Receipt and Storage" last reviewed April 07, 2014, revealed, "...E. All Foods not stored in original containers should be labeled and dated. F. All food should be dated when opened. ..."
An observation on June 8, 2015, of the walk in freezer and walk in refrigerator revealed containers of green peppers, onions, raspberries, cucumbers, lettuce that were removed from their original containers. None of the items had a use by date.
An observation on June 8, 2015, of various refrigerators revealed a container of pickles, garlic, broccoli, celery and icing that were not dated when opened. The dry storage area had an opened bag of macaroni that was not dated when opened. There were tubs of brown sugar and flour that did not have an open date on them.
An interview conducted on June 8, 2015, at 10:30 AM with EMP4 confirmed that the food items had been removed from their original containers and did not have a use by date and the open items did not have a date they were opened.
A review of facility policy " Infection control" effective May 11, 2015, revealed "...5. Hair nets or hats are worn by all employees. All hair must be tucked under the hat or hair net.
A tour of the kitchen on June 8, 2015, revealed four dietary employees that had their bangs and hair on the sides out of the hair net. One dietary employee was not wearing a hair net. Their hair was swept up and then had a covering on the crown of their head.
An interview conducted on June 8, 2015, at 10:00AM with EMP4 confirmed all five employees did not have their hair covered according to facility policy.
Further review of facility policy "Cleaning of Convection Ovens" effective date July 30, 2014, revealed, "...The cooks and the baker are responsible for cleaning and maintaining the cleanliness of the ovens. "
A tour of the kitchen revealed the lips of four ovens contained dried brown residue. The area under the garbage disposal contained a build up of dried brown residue. There were two tiles in the dishwasher area and one tile by the steam jacket kettle that had large chunks out that exposed drywall.
An interview conducted on June 8, 2015, at 11:00AM with EMP4 confirmed that the lips of the ovens were not cleaned effectively, the garbage disposal area had a build up of residue and the tiles needed to to repaired and they had not submitted a work order to repair the tiles.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the facility followed their established policy for the Utilization Review (UR) committee meeting schedule and that two physicians attended the UR Committee meetings.
Findings Include:
A review on June 10, 2015, of the facility "Utilization Management Plan," last reviewed July 18, 2014, revealed "... F. Utilization Review Committee 2. The Utilization Review Committee shall be comprised of the Chairman of the MEC, who will serve as chair, the Associate Medical Director and at least one other physician with active Medical Staff privileges appointed by the MEC. ... 4. The Utilization Review Committee shall meet at a minimum of every other month.
A review on June 10, 2015, of the facility's Utilization Review Committee meeting minutes from February 2014 to February 2015 revealed that the facility failed to have a Utilization Review Meeting for the months of June and December 2014. Further review revealed that the Chairman of the MEC did not attend any of the Utilization Review Meetings. Only one physician attended the following meetings: April 10, 2014, September 4, 2014, October 2, 2014, and February 5, 2015.
An interview conducted on June 10, 2015, at 9:40 AM with EMP5 revealed that the "Chairman of the MEC never comes to the meetings. He is too busy to come." Further interview confirmed that the facility failed to have a UR meeting in June and December 2014 and the second physician did not attend four of the five UR meetings.

Based on review of facility policy, documentation and interview with staff, it was determined that the Utilization Review (UR) committee meeting minutes failed to provide evidence that outlier cases for admission or length of stay were reviewed.

Findings include:

A review on June 10, 2015, of the facility "Utilization Management Plan," last reviewed July 18, 2014, revealed:

"1. Admission Reviews ... b. All admissions shall be screened for appropriateness of admission using Philhaven's Medical Necessity Criteria for Admission and, when appropriate, that of other agencies. c. If the medical necessity or appropriateness of an admission does not appear to meet Philhaven's admission criteria, or if the admission does not appear to meet the medical necessity criteria of the Health Plan or their delegated managed behavioral care organization, Access Center will contract the Physician/Administrator on call for a determination."

"2. Continues Stay Reviews ... b. The Utilization Specialist will conduct continued stay reviews in accordance with the review schedule established by the Health Plan or their delegated managed behavioral care organization. b. If the Physician-to-Physician review results in a non-authorization determination, the UM Specialist will coordinate a first level appeal with the Attending Physician and the physician from the managed Behavioral Health Care Organization. Specific medical necessity criteria not met and any identified quality of care issues will be discussed with the Attending Physician and the Medical Director.

A review of the UR committee minutes from February 6, 2014, to February 5, 2015, failed to reveal any evidence of review of outlier cases necessity of admission or continued length of stay.

An interview conducted on June 11, 2015, at 9:40 AM with EMP5 revealed that the facility very seldom has any cases to be reviewed for the necessity of admission. Further interview revealed that the facility continuously tries to find placement for their outlier length of stay patients. EMP5 confirmed that the necessity of admission and continued length of stay was not addressed in the UR Committee minutes from February 6, 2014, to February 5, 2015, and evidence could not be provided that reviews were done.

Based on review of facility policy, documentation and interview with staff, it was determined that the Utilization Review Committee minutes failed to provide evidence that they reviewed the outlier cases for their continued length of stay.

Findings include.

A review on June 10, 2015, of the facility "Utilization Management Plan," last reviewed July 18, 2014, revealed:

"2. Continued Stay Reviews a. The Utilization Specialist will conduct continued stay reviews in accordance with the review schedule established by the Health Plan or their delegated managed behavioral care organization. b. Continued stay reviews shall address medical necessity, patient response to the treatment plan, appropriateness of discharge planning efforts and appropriate utilization of services and resources."

A review of the UR committee minutes from February 6, 2014, to February 5, 2015, failed to reveal any evidence of review of outlier cases for continued length of stay.
An interview conducted on June 11, 2015, at 11:20 AM with EMP6 confirmed that the facility was on a Perspective Payment System.
An interview conducted on June 11, 2015, at 10:00AM with EMP5 revealed that the facility reviews all the outlier cases for continued length of stay. The interview also confirmed that there is no mention of review of outlier cases for continued length of stay in the UR Committee minutes from February 6, 2014, to February 5, 2015.

Based on review of facility policy, documentation and interview with staff, it was determined that the facility failed to review their professional services provided to the patient.

Findings include:

A review on June 10, 2015, of the facility "Utilization Management Plan," last reviewed July 18, 2014, revealed:

"2. Continued Stay Reviews ... b. Continued stay reviews shall address medical necessity, patient response to the treatment plan, appropriateness of discharge planning efforts and appropriate utilization of services and resources."

A review on June 10, 2015, of the facility's Utilization Review Committee meeting minutes from February 2014 to February 2015 revealed that the facility failed show evidence that their professional services were reviewed.

An interview conducted on June 10, 2015, at 10:15 AM with EMP5 confirmed that the facility did not review their professional services to determine most efficient use of their facilities and services.

This Condition Level deficiency is the result of a Life Safety Code survey completed on June 4, 2015.

Based on review of facility policies, medical record (MR), and interview with staff (EMP), it was determined the facility did not properly implement the discharge plan, by failing to list the changes from the patient's pre-admission medications, for two of four closed discharge medical records (MR) reviewed (MR 13 and MR16).

Findings include:

A review on June 8, 2015, of the Philhaven Hospital policy 2000.006 " Verification/Reconciliation medication for Prescribers " last reviewed February 5, 2015, revealed " ... At the time of discharge the client and family (as needed) will be provided with the written information on the medication they should be taking when discharged ... " The policy did not address the specific medication changes from pre-admission and discharge.

A review on June 8, 2015, of MR 13 and MR16 revealed the list of medications the patient should be taking after discharge did not contain clear indications of changes from the patient's pre-admission medications.

An interview conducted on June 8, 2015, at 3:00 PM with EMP7 confirmed the list of medications did not contain clear indications of changes from the patient's pre-admission medications.

Based on observations, staff and patient interview, medical record review, and facility document review there is a systematic failure of the facility to provide medical records that document the treatment given to patients and the facility staff who are provided the services:

Findings include:

1. There was a failure to ensure the social work assessments for eight (8) of eight (8) active sample patients. Based on medical record review and interview, it was determined that in eight (8) of eight (8) sample patients (patients A1, A2, A3, A4, A5, A6, A7 and A8), there was no Psychosocial Assessment. (Refer to B108)

2. The facility did not provide adequate review to assure that treatment care planning is completed for all patients. Based on medical record review and interview, it was determined that in three (3) of eight (8) sample patients (patients A3, A4 and A8), that the master treatment plan did not have input from all required discipline's. (Refer to B118)

3. Lack of Medical/Psychiatrist attendance at treatment planning meetings. There is no documentation to confirm that the Medical/Psychiatrist attends all care plan meetings. This practice has the potential to have patient care not under the direction of a physician and potentially compromise a patient's medical and psychiatric care. (See B118)

4. The facility staff failed to accurately update Master Treatment Plan (MTP) of one (1) of eight (8) sample patients (patient A7). (Refer to B122)

5. Based on record review and interview, the facility failed to ensure the names of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) of six (6) of eight (8) active sample patients (A3, A4, A5, A6, A7 and A8). (Refer to B123)

A. Based on medical record review and interview, it was determined that in eight (8) of eight (8) sample patients (patients A1, A2, A3, A4, A5, A6, A7 and A8), there was no Psychosocial Assessment and thus no description of the anticipated role of social work staff in the patient's treatment while hospitalized. This failure results in a lack of information being provided for the treatment team about what anticipated social service interventions will be provided.

Medical Record Review

Patient A1: The Integrated Assessment dated 4/30/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A2: The Integrated Assessment dated 4/2/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A3: The Integrated Assessment dated 4/6/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A4: The Integrated Assessment dated 5/14/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A5: The Integrated Assessment dated 5/19/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A6: The Integrated Assessment dated 5/30/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A7: The Integrated Assessment dated 5/28/15 included minimal psychosocial data but no recommendations for social service interventions.

Patient A8: The Integrated Assessment dated 5/18/15 included minimal psychosocial data but no recommendations for social service interventions.

Staff Interview:

The Director of Social Work was interviewed on 6/9/15 at 11:00 a.m. The Director agreed that complete Psychosocial Assessments were not present in the medical record.

B. Based on medical record review and staff interview, the facility failed to ensure that social work interventions were included in the Master Treatment Plans (MTP) of six (6) of eight (8) sample patients (patients A3, A4, A5, A6, A7 & A8). This failure results in the necessity for staff to rely on oral communication regarding the focus of treatment.

Medical Record Review:

The MTP of patient A3, dated 4/7/15, contained no social work interventions.

The MTP of patient A4, dated 5/14/15, contained no social work interventions.

The MTP of patient A5, dated 5/19/15, contained no social work interventions.

The MTP of patient A6, dated 5/31/15, contained no social work interventions.

The MTP of patient A7, dated 5/29/15, contained no social work interventions.

The MTP of patient A8, dated 5/19/15, contained no social work interventions.

Staff Interview

In an interview on 6/9/15 at 11:00 a.m, the Director of Social Work acknowledged that social work interventions were not consistently present in treatment plans.

Based on record review and interview, the facility failed to ensure that appropriate treatment planning occurred for the care and treatment for three (3) of eight (8) active sample patients (A3, A4 and A8). Specifically, the treatment plans for these patients were not developed using an interdisciplinary approach and were not updated to reflect their assessed needs. Therefore, there was no interdisciplinary written plan of care for these active sample patients. The Master Treatment Plans (MTPs) were developed by nursing staff, with no input from other disciplines... This failure results in patients being without any written interdisciplinary treatment plan to provide guidance to all disciplines to assist them in providing treatment, potentially resulting in patients' treatment needs not being met.

Findings Include:

A. Document Review:

1. A copy of Treatment Team Meeting Schedules was requested for each of the active sample patients. Facility staff was unable to provide the schedules as Interdisciplinary Treatment Team Meetings are not held on the East, West, and Inpatient Extended Behavioral programs.

2. The facility "Policy and Procedure Manual, Subject: Treatment Plan," dated 8/6/12 and effective 5/27/14, stated, "The Treatment Plan is a tool that guides the treatment and facilitates continuity of care. The Treatment Plan is a record of the treatment decisions made by the team...."

B. Interview:

1. During interview on 6/9/15 at 1:45 p.m. with Clinical Director 1, Treatment Plan Meeting Schedules were discussed. S/he acknowledged that Treatment Plan Meetings are not held on the East, West, and Inpatient Extended Behavioral programs, and therefore Treatment Plan Meeting Schedules do not exist.

2. During interview on 6/9/15 at 3:00 p.m. with the Assistant Medical Director, Treatment Plans were discussed. He acknowledged, "We do have problems with Treatment Plans."

Based on medical record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) of one (1) of eight (8) sample patients (patient A7) was revised to include updated interventions to assist the patient in control of aggression following the use of seclusion. This failure results in a lack of direction to guide staff in the use of specific individualized intervention(s) to prevent aggression.

Medical Record Review:

Patient A7, an 8 year-old boy, was admitted on 5/28/15 because of aggressive behavior toward others at home and at school. He was secluded on 5/30/15, 6/1/15, and 6/5/15 because of aggression toward himself and others. Review of the most recent updated MTP, dated 6/8/15, revealed that no interventions had been added to the MTP to address this problem.

Staff Interview:

RN 3, in an interview on 6/9/15 at 10:30 a.m., was asked to point out revision of the MTP made as a result of the three (3) episodes of seclusion. RN stated "It's not there."

Based on record review and interview, the facility failed to ensure that the name of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans (MTPs) of six (6) of eight (8) active sample patients (A3, A4, A5, A6, A7 and A8). Only Registered Nurses are listed as responsible for all MTP interventions. Additionally, the facility failed to list duration and frequency of interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8. These deficient practices resulted in the facility's inability to monitor staff accountability for specific treatment modalities.

Medical Record Review:

The MTP of patient A1, dated 6/4/15 contained no duration and frequency for interventions.

The MTP of patient A2, dated 6/4/15 contained no duration and frequency for interventions.

The MTP of patient A3, dated 4/7/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

The MTP of patient A4, dated 5/14/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

The MTP of patient A5, dated 5/19/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

The MTP of patient A6, dated 5/31/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

The MTP of patient A7, dated 5/29/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

The MTP of patient A8, dated 5/19/15, contained no responsible discipline, other than nursing, for all interventions. Duration and frequency for interventions were not present.

Staff Interview:

In an interview on 6/9/15 at 10:00 a.m., the Director of Nursing acknowledged that responsible disciplines, other than nursing, and frequency and duration of interventions were not consistently present in treatment plans.

Based on medical record review and interview, it was determined that the Medical Director failed to monitor the treatment planning process to ensure that patient problems were addressed with appropriate goals and modalities that were implemented by each member of the treatment team in eight (8) of eight (8) sample patients (patients A1,A2,A3,A4,A5,A6, A7 & A8).

Medical Record Review: Refer to B118 and B123

Staff Interview:

In the absence of the Medical Director, the Associate Medical Director was interviewed on 6/9/15 at 3:00 p.m. When informed of the deficiencies in the master treatment plans which were reviewed, the Associate Director responded, "We have problems with the treatment plans."

Based on medical record review and interview, it was determined that the Director of Nursing failed to monitor the treatment planning process to ensure that patient problems were addressed with appropriate goals and modalities that were implemented by each member of the treatment team in eight (8) of eight (8) sample patients (patients A1,A2,A3,A4,A5,A6, A7 & A8).

Medical Record Review: Refer to B118 and B123

Staff Interview:

The Director of Nursing was interviewed on 6/9/15 at 2:00 p.m. When informed of the deficiencies in the master treatment plans which were reviewed, the Director of Nursing acknowledged that there are problems with the treatment plans.

Based on medical record review and interview it was determined that the Director of Social Work failed to ensure that Psychosocial Assessments were completed on eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 & A8) and failed to monitor the quality and appropriateness of social work services furnished by the facility. Without monitoring there is a potential for major gaps in the provision of social services.

Medical Record Review: Refer to B108, B118, B123

Staff Interview:

In an interview on 6/9/15 at 11:00 a.m., the Director of Social Work stated that s/he had no supervisory responsibilities for any social service providers and that s/he did not regularly monitor social service providers' documentation in the medical record.