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Based on document review, medical record review and interview, the facility does not ensure patient transfers to other facilities are conducted in accordance with facility policy and procedure as evidenced for 2 of 30 patients (Patient #14 and #18).

Findings include:

Review on 06/06/19 of policy "Emergency Medical Transports" last revised 05/2019 revealed once the Interinstitutional Transfer Record is completed, the physician assesses and signs in section 1. In emergency situations and if the physician is not available, the Supervisor signs the form.

Medical record review on 06/06/19 revealed the following:
- Patient #14 was transferred to an area emergency room on 02/17/19. There was no evidence of an inter-institutional transfer form in the medical record.
- Patient #18 was transferred to an area emergency room on 01/30/19. There is no evidence a physician or registered nurse signed the Interinstitutional Transfer Record.

Interview on 06/06/19 at 02:00PM with Staff (B), VP Corporate Compliance, verified these findings.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 06/03/15

Based on observation, document review, medical record review and interview, the facility did not ensure all patients or their representative are informed of the patient's rights.

Findings include:

Review on 06/06/19 of policy "Admissions Process" last revised 05/2014 revealed the following documents are required to be signed by the patient or legal representative: Notice of Status and Rights. If the patient is a minor or is unable to sign the forms a family member or legal representative may sign the forms.

Observation on 06/04/19 at 09:00 AM in the facility main waiting room and at 09:30 AM on the adolescent inpatient unit revealed a copy of the New York State (NYS) Paren'ts Bill of Rights is not posted.

Medical record review on 06/06/19 revealed no documentation to indicate the patient's parent/guardian received the NYS Parent's Bill of Rights (Patient #6, 17 and 22) or Patient's Bill of Rights (Patient #2, 3, 28 and 29).

Review on 06/06/19 at 10:00 AM of registration packet given to the parent/guardian of newly admitted pediatric patients did not include a copy of the Parent's Bill of Rights.

Review on 06/06/19 at 11:00AM of registration information given to outpatient patients did not include a copy of the Patient's Bill of Rights.

Interview on 06/06/10 at 02:00PM with Staff (B), VP Corporate Compliance, verified the above findings.

Based on credential file review, document review and interview, the facility did not provide training in the prevention and management of crisis situations (PMCS) to all appropriate staff. Specifically, there is no evidence training is provided to 3 of 3 physicians who are authorized to order restraint or seclusion. (Staff G, M and N)

Findings include:

Review of credential files on 06/05/19 for Staff (G),(M) and (N), Physician, revealed no evidence of training in PMCS.

Interview on 06/05/19 at 12:00 PM with Staff (JJ), Medical Staff Credential Coordinator revealed physicians do not receive PMCS training.

Review on 06/05/19 of Medical Staff Rules & Regulations dated 2016 revealed the primary medical provider must conduct an in-person patient assessment and write and sign the order for restraint or seclusion.

Interview on 06/06/10 at 02:00PM with Staff (B), VP Corporate Compliance, verified the above findings.

Based on medical record review, policy review, and interview the facility did not ensure nursing staff develop and keep current a nursing plan of care for 3 of 30 patients (Patient #4, 7 and 23).

Findings include:

Review on 06/06/19 of policy, Multidisciplinary Treatment Plan, last reviewed 01/2019 revealed a comprehensive individualized treatment plan is developed for each patient by the multidisciplinary treatment team within 24-48 hours of admission. The treatment plan takes into account cultural, spiritual, and social factors as well as the characteristics, conditions, and circumstances of the patient.

Medical record review on 06/06/19 revealed the Individualized Patient Centered Treatment Plan (IPCTP) did not include nursing interventions for the patient's identified medical conditions as follows:
- Patient #4: Admission psychiatric assessment dated 05/30/19 revealed admission diagnosis of diabetes, migraine headaches, chronic back pain and muscle pain which was not reflected in the IPCTP.
- Patient #7: Physician history and physical dated 05/31/19 revealed patient assessment of low back pain and migraines, which was not reflected in the IPCTP.
- Patient #23: Admission psychiatric assessment dated 02/08/19 revealed admission diagnosis of gastroesophageal reflux disease (GERD) and hypertension (HTN), which was not reflected in the IPCTP.

Interview on 06/06/10 at 02:00PM with Staff (B), VP Corporate Compliance, verified the above findings.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 06/03/15

Based on medical record review, policy review and interview, the facility did not ensure patient discharge summaries are authenticated for 2 of 30 medical records (Patient #20 and 21).

Findings include:

Review on 06/07/19 of Medical Staff Rules and Regulations dated 2016 revealed it is permissible for the Attending Physician to delegate responsibility for dictation of the discharge summary. However, the Attending Physician must assume full responsibility for accuracy and completeness as evidenced by their signature.

Medical review on 06/06/19 revealed the patient discharge summary, dictated by the nurse practitioner, was not signed by the physician for Patient #20 who was discharged on 04/02/19 and Patient #21 who was discharged on 06/06/19.

Interview on 06/06/10 at 02:00PM with Staff (B), VP Corporate Compliance, verified these findings.


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Based on observation and interview the facility did not adequately maintain the facility.

Findings include:

During the facility tour on 06/04/2019 at 10:30AM the following was observed:
- The dishwasher final temperature reached 162 degrees Farenheit. There was a sticker affixed to the final rinse gauge indicating the minimum temperature must be 180 degrees Farenheit.
- The mop sink, which was 2-feet by 2-feet, was full of brown water.

Interview on 06/04/2019 at 10:45AM with Staff (H) Dietary indicated that the mop sink was not in use and that heavy rains caused water to fill the sink.

Interview on 06/04/2019 at 11:00AM with Staff (B), VP of Corporate Compliance, verified the above findings.



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Based on policy and procedure review, personnel file review, document review, and interview, the facility does not ensure that the infection control officer has a system for identifying, reporting, investigating and controlling infections and communicable diseases, specifically;

1.) The health of personnel is not assessed with action taken as needed for 4 of 15 clinical staff (Staff K, L, M and N)
2.) A sanitary kitchen environment is not maintained.

Findings include:

Finding #1:
Review on 06/06/19 of policy "Employee Health Compliance" last reviewed 12/2016 revealed all medical staff members that have privileges to practice at the facility will be required to provide annual health assessment and tuberculosis skin testing (TBT).

Personnel file review on 06/05/19 revealed the files for Staff (K), (L), (M) and (N) did not contain evidence of a current health assessment and the files for Staff (K), (L) and (M) did not contain evidence of a current TBT.

Interview on 06/05/19 at 12:00 PM with Staff (JJ), Medical Staff Credential Coordinator, confirmed these findings.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 06/03/15.

Finding #2:
Observation on 06/04/2019 at 11:00AM of the facility kitchen revealed 60 pieces of raw chicken sitting in a sink full of water. The water from the faucet was not running. The sink basin size would not allow for the water to be run with that amount of chicken.

Interview on 06/04/2019 at 11:00AM with Staff (H), Dietary Manager, verified the above findings. Staff (H) stated that the chicken was thawing

Based on record review and staff interview, it was determined that the Psychiatric Evaluations for four (4) of eight (8) patients (Patients C, D, E and G) lacked a description of the patient's memory functioning. This failure resulted in no information being provided to the other members of the multidisciplinary treatment team to aid in their selection of treatment interventions appropriate to the patient's intellectual functioning.

Findings include:

A. Record Review:

The following Psychiatric Evaluations (dates of evaluations in parenthesis) had no descriptions of memory functioning): Patient C (5/11/19), Patient D (5/17/19), Patient E (5/24/19 and Patient G (5/04/19.
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B. Staff Interview:

On 6/05/19 at 9:25 a.m. the facility's clinical director was interviewed. A partial focus was the lack within Psychiatric Evaluations of an estimate of memory functioning. The clinical director agreed that this component was an important part of a mental status examination and should be present.

Based on record review and staff interview it was determined that for five (5) of eight (8) patients (Patients D, E, F, G and H) the Psychiatric Evaluations failed to describe patient assets in descriptive, mot interpretive fashion. This failure results in no information being made available to the other members of the multidisciplinary treatment team about what patient strengths might be utilized in the selection of treatment modalities during hospitalization.

Findings include:

A Record Review:

1. Patient D: The Psychiatric Evaluation, dated 5/17/19, had no description of the patient's assets.

2. Patient E: The Psychiatric Evaluation, dated 5/24/19, stated as the patient's assets "Supportive father, does go to school." There was no information about what the patient enjoys doing, what hobbies or areas of interest or accomplishments there might be.

3. Patient F: The Psychiatric Evaluation, dated 5/21/19, stated as the sole patient asset "Supportive mother."

4. Patient G: The Psychiatric Evaluation, dated 5/04/19, stated as the patient assets "Supportive family, willing to seek help."

5. Patient H: The Psychiatric Evaluation, dated 5/19/19, stated as the patient assets "[He/she] is physically healthy and is going through treatment."

B. Staff Interview:

On 6/05/19 at 9:15 a.m. the facility's clinical director was interviewed. A partial focus of the interview was the findings described in Section A, above. The clinical director agreed that determining what assets the patient brought during hospitalization could be very helpful in the selection of treatment modalities.

Based on record review and staff interviews, it was determined that the Master Treatment Plans for seven (7) of eight (8) patients (Patients B, C, D, E, F, G and H) had been written before various disciplines had completed their respective assessments. This failure results in the formulation of Master Treatment Plans including the setting of goals by the multidisciplinary treatment team before assessments had occurred.

Findings include:

A. Record Review:

I. Master Treatment Plans created before assessments completed:

1. Patient B: The Master Treatment Plan, dated5/17/19, was created before the Psychiatric Evaluation dated 5/19/19 and the Psychosocial Assessment dated 5/18/19 had been done.

2. Patient C: The Master Treatment Plan dated 5/11/19, was created before the Psychosocial Assessment dated 5/12/19 had occurred.

3. Patient D: The Master Treatment Plan, dated 5/16/19, was created before the Psychiatric Evaluation dated 5/17/19 and the Psychosocial Assessment dated 5/18/19 had occurred.

4. Patient E: The Master Treatment Plan, dated 5/23/19, was created before the Psychiatric Evaluation, dated 5/24/19, and the Psychosocial Assessment, dated 5/27/19, had occurred.

5. Patient F: The Master Treatment Plan, dated 5/20/19, was created before the Psychiatric Evaluation, dated 5/21/19, had occurred.

6. Patient G: The Master Treatment Plan, dated 5/03/19, was created before the Psychiatric Evaluation, dated 5/04/19, and the Psychosocial (Update) Assessment, dated 5/04/19, had occurred.

7. Patient H: The Master Treatment Plan dated 5/17/19 was created before the Psychiatric Evaluation, dated 5/19/19, had occurred.

In addition, the facility failed to ensure that:

II. Treatment Goals were described in a behaviorally, measurable fashion: See, B121 for details.

III. Treatment Modalities were individualized and were more than a description of generic discipline tasks. See, B122 for details.

IV. Responsible staff were identified for assuring the monitoring of and adherence to the modalities selected. See, B123 for details.

B. Staff Interviews:

1. On 6/05/19 the clinical director was interviewed. A partial focus of the interview was the findings described in Section I, above. The clinical director agreed that all necessary discipline assessments should be completed before the multidisciplinary team set patient goals and interventions.

2. On 6/05/19 at 9:50 a.m. the surveyors interviewed the Director of Nursing and discussed the findings described in Section I, above. The Director agreed that the dates were confusing and that assessments should occur before a multidisciplinary Treatment Plan was created.

3. On 6/05/19 at 8:40 a.m. the facility's LMHC (Licensed Mental Health Counselor) Social Work Coordinator and the MSW (Masters Social Worker) were interviewed. Both agreed that Master Treatment Plans should be created after appropriate discipline assessments had been completed.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric condition for seven (7) of eight (8) active patients' (B, C, D, E, F and G and H). Most of the goals were not measurable. Without a set of defined goals against to measure progress, it is difficult to judge effectiveness of treatment and implement possible changes in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. In patient B's MTP, dated 5/22/19, for the problem "Depression" as evidenced by: "Pt [patient] reports of depression + S/I [plus suicidal ideation]," the difficult-to-measure short-term goal was: "[Name of patient] presenting symptom of depression will diminish while in the hospital for 5 days AEB (As Evidenced By) replacement feeling of positive self-regard."

2. In patient C's MTP, dated 5/1/19, for the problem "Depression" as evidenced by: "Reports 'want to die'," the difficult-to-measure short-term goal was "[Name of patient] presenting symptoms." The rest of the pre-printed goal was blank.

3. In patient D's MTP, dated 5/17/19, the problem "Depression, anxiety, feels helpless, hopelessness," the difficult-to-measure short-term goal was "[Name of patient] presenting symptoms of depression, hopelessness will diminish while in the hospital for 7 days, AEB replacement of feelings of hopelessness or thoughts of positive thoughts."[sic]

4. In patient E's MTP, dated 5/30/19, for the problem "Altered mental health state," the difficult -to- measure short-term goal was "[Name of patient] presenting symptoms of altered mental health state will diminish while in the hospital for 7 days AEB replacement feelings of hope, stable mood, and cooperative behaviors free from thoughts of self-harm."

5. In patient F's MTP, dated 5/27/19, for the problem "A/H [Auditory/ Hallucinations] to harm-self, animals as evidenced by recent attempts to kill a frog," the difficult-to-measure short-term goal was "[Name of patient]'s presenting symptoms of A/H to harm animal, self will diminish while in the hospital 7 - 10 days AEB replacement feelings of well-being or thoughts of development of + [positive] coping skills."

6. In patient G's MTP, dated 5/10/19, for the problem "Depression as evidenced by: SI, anxiety," the difficult-to-measure short-term goal was "[Name of patient] presenting symptoms of depression will diminish while in the hospital for 7 - 10 days AEB replacement feelings for hopelessness or thoughts of wanting to harm self."

7. In patient H's MTP, dated 5/24/19, for the problem "Aggression and assaultiveness as evidenced by attacked art teacher, hit mom," the difficult -to-measure short-term goal was "[Name of patient] presenting symptoms of aggression will diminish while in the hospital for 7 days AEB replacement of feeling of anger or thoughts of SI [suicidal ideations] and HI [Homicidal Ideations]."

B. Interviews

1. In an interview on 5/15/19 with the Director of Nursing at 9:50 a.m., the difficult-to-measure short-term goals were discussed. He agreed with the findings.

2. In an interview with RN1 on 5/15/19 around 10:15 a.m., the difficult-to-measure short-term goals were discussed. RN1 stated, "I see what you mean."

Based on record review and interview, the facility failed to ensure that Master Treatment Plans [MTPs] contained individualized active treatment interventions with a focus or purpose based on the presenting psychiatric problems and treatment goals of eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G, and H). Instead, the MTPs included routine discipline functions rather than individualized active interventions to assist the patient's recovery. This deficiency resulted in a failure to guide treatment staff regarding the specific treatment modality and purpose for care, and inconsistent and/or ineffective treatment.

Findings include:

1. Patient A's MTP, dated 6/3/2019, for the problem "Anxiety" as evidenced by "Pt [patient] state [sic] can't handle [his/her] feeling," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects 2 times in 5 days so that the patient does not refuse any medication."

2. Patient B's MTP, dated 5/22/2019, for the problem "Depression as evidenced by pt. reports of depression, + S/I [plus suicidal ideation]," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects 2 times in 5 days so that the patient does not refuse any medication."

3. Patient C's MTP, dated 5/1/2019, for the problem "Depression as evidenced by "Reports 'want to die'," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects (blank for time) times in (blank for time) days so that the patient does not refuse any medication."

4. Patient D's MTP, dated 5/17/2019, for the problem "Depression, anxiety, feeling helpless, hopeless," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects 1 times in 7 days so that the patient does not refuse any medications"

5. Patient E's MTP, dated 5/30/2019, for the problem "Altered mental health state," as evidenced by "SI, anxiety, hopelessness, impulsivity," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects of medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects 2 times in 7 days so that the patient does not refuse any medication."

6. Patient F's MTP, dated 5/27/2019, for the problem "A/H to harm self, animals as evidenced by recent attempt to kill frog," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding indications and side effects 2 time in 7 days so that the patient does not refuse any medication."

7. Patient G's MTP, dated 5/10/2019, for the problem "Depression + SI, anxiety," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding ideations and side effects 1 times [sic] in 7 days so that the patient does not refuse any medication."

8. Patient H's MTP, dated 5/24/2019, for the problem "Aggression & Assaultive Behavior as evidenced by attacked art teacher, hit mom," the generic physician intervention was: "Physician will meet with the patient daily to monitor changes in symptoms and assess and adjust medication / treatment as needed. Physician will monitor and educate regarding precautions, risks, benefits, and side effects on medications."

The generic nursing intervention was "Nursing will administer medication every day as ordered by physician and monitor side effects. Nursing will provide health teaching regarding ideations and side effects 2 times in 7 days so that the patient does not refuse any medication."


B. Interviews

1. In an interview on 5/15/2019 at 9:30 a.m. with the Director of Nursing, the generic nursing interventions on the Master Treatment Plans was discussed. He agreed with the findings.

2. In an interview on 5/15/2019 with RN1 around 10:15 a.m., the generic nursing interventions were discussed. She stated, "I agree with what you are saying."

Based on record review and staff interview it was determined that for five (5) of eight (8) patients (Patients A, B, C, E and G) the Master Treatment Plans failed to identify the responsible person who provided and/or monitored the treatment modalities described. This failure resulted in the facility being unable to hold responsible staff accountable.

Findings include:

I. Record Review:

1. Patient A: The Master Treatment Plan dated 6/03/19 lacked signatures of Clinical Counselor and Therapeutic Activities.

2. Patient B: The Master Treatment Plan dated 5/17/19 did not identify the physician responsible for the psychiatric intervention for Problem #1.

3. Patient C: The Master Treatment Plan dated 5/10/19 did not identify the physician responsible for the psychiatric intervention for Problem #1.

4. Patient E: The Master Treatment Plan dated 5/23/19 did not identify the physician responsible for the psychiatric intervention for Problem #1.

5. Patient G: The Master Treatment Plan dated 5/03/19 did not identify the physician responsible for the psychiatric intervention for Problem #1.

II. Staff Interview:

On 6/05/19 at 9:15 a.m. the clinical director was interviewed. A partial focus of the interview was the findings described in Section I, above. He agreed that responsible staff need to be identified on the Master Treatment Plan.

Based on record review and staff interviews it was determined that the clinical director failed to ensure:

1. Psychiatric Evaluations contained an assessment of memory functioning in the mental status exam. See B116 for details.

2. Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. See B117 for details.

3. Master Treatment Plans were written after discipline assessments had been completed. See B118 for details.

4. Master Treatment Plans contained goals that were observable, and behaviorally measurable. See B121 for details.

5 Master Treatment Plans contained treatment modalities that were patient specific and were more than generic discipline tasks. See B122 for details.

6. Master Treatment Plans disclosed responsible staff for modalities selected. See, B123 for details.

These failures resulted in a lack of information about the patient that could be utilized in the selection of treatment modalities and that Master Treatment Plans were incomplete and established before discipline assessments had been made.

Based on record review and interview, the Director of Nursing failed to:

1. formulate treatment goals that were relevant to the patients' psychiatric condition for seven (7) of eight (8) active patients (B, C, D, E, F, G and H). Most of the goals were not measurable. Without a set of defined goals against to measure progress, it is difficult to judge effectiveness of treatment and implement possible changes in treatment in the case of lack of progress. Refer to B121

2. ensure that Master Treatment Plans [MTPs] contained individualized active treatment interventions with a focus or purpose based on the presenting psychiatric problems and treatment goals of eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). Instead, the MTPs included routine discipline functions rather than individualized active interventions. Refer to B122

Based on document review and interview the facility did not review and update their emergency preparedness plan or conduct a risk assessment using an all hazard approach.

Findings include:

Review on 06/05/2019 at 3:15PM of the facility emergency preparedness plan dated 2016 revealed no evidence of an annual review.

Review on 06/05/2019 at 3:15PM of the emergency preparedness plan dated 2016 revealed no evidence of an all-hazards approach as there was no risk assessment contained in the plan.

Interview on 06/06/19 at 02:30PM with Staff (B), VP of Corporate Compliance, verified the above findings.