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Based on medical record review and staff interview, it was determined that three (3) of eight (8) Psychiatric Evaluations for active sample patients (1, 5, and 6) failed to include an assessment of patient assets in descriptive, not interpretive fashion. This failure results in no information being available to other members of the multidisciplinary team about what interests and accomplishments might be considered in the selection of treatment modalities.

Findings include:

A. Medical Record Review

1. Patient 1: The Psychiatric Evaluation dated 3/08/18 had as the sole patient asset, "Access to healthcare."

2. Patient 5: The Psychiatric Evaluation dated 3/14/18 had no assets described.

3. Patient 6: The Psychiatric Evaluation dated 3/15/18 had "[He/she] has access to health care" and "Good support system."

B. Staff Interview

On 2/21/18 at 12:45 p.m., the psychiatrist covering for the clinical director was interviewed. When told of the findings described in Section I, above he concurred with the findings.

Based on record review and interview, the facility failed to develop Master Treatment plans (MTPs) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 5, 6, 7, and 8) that included individualized physician interventions based on specific needs of each patient. The physician interventions were identical on all of the eight (8) patients' MTPs. Failure to clearly describe specific modalities by physicians can hamper their ability to identify individualized expected patient outcomes in a manner that can be utilized by the treatment team to measure the effectiveness of treatment and/or progress towards discharge.

Findings include:

A. Record Review

A review of MTPs (dates of MTPs in parenthesis) revealed the following physician intervention: "Medical provider will meet with patient daily to educate patient re: Course of illness, and assess medication effects, including side effects." This intervention was included on the plans for all patients in the active sample 1 (3/7/18), 2 (3/5/18), 3 (3/16/18), 4 (3/9/18), 5 (3/13/18), 6 (3/14/18), 7 (3/7/18), and 8 (3/9/18).

B. Interview

1. In an interview on 3/21/18 at 9:00 a.m., the generic physician interventions, which were written by the nursing staff, was discussed with the Director Nursing. She did not dispute the findings.

2. In an interview on 3/22/18 at 12:42 p.m., the generic and non-individualized physician interventions on the MTPs were discussed with the covering clinical/Medical Director. He agreed with the findings.

Based on staff interview, it was determined that the facility did not have available psychological services to meet the needs of the patients. This failure results in an inability by the psychiatric staff to obtain diagnostic clarification or obtain expertise in behavior modification techniques and other psychology discipline services

Interview

On 3/20/18 at 3:25 p.m., the facility's C.E.O. was interviewed. The C.E.O. stated, "There is nobody here currently." The C.E.O also reported that they had no contractual agreement presently with a psychologist to provide services.