HospitalInspections.org

Based on observations as referenced in the Life Safety Report of Survey completed February 22, 2017 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Women's Dorm 1 & 2

1. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. The battery powered light wass not functioning in corridor area near room #7.

b. The exit discharge was not complete to publicway with emergency lighting - existing lighting, near room #8, will not cover path to publicway.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Men's Dorm 1, 2, & 3

2. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

There was no exit discharge lighting to illuminate exit path to publicway - exit discharge near room #13.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Acute Care Unit

3. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. There was no exit discharge lighting to illuminate exit path to public way - exit discharge near room B108.

b. Exit discharge path serving activity gym and acute care unit was not equipped with emergency lighting to cover entire egress path to public way.

c. The generator annunciator panel failed to indicate generator switch in the off position at time of arrival to facility.

d. The generator annunciator panel failed to indicate emergency power system supplying load during loss of normal power to the automatic transfer switch.

e. The emergency power system test was not documented for review - there were no thirty minute monthly load test or weekly inspection documents available for review.

f. There was no remote manual stop switch for emergency generator - switch shall be located remote from generator enclosure.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations as referenced in the Life Safety Report of Survey completed Fabruary 22, 2017, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

The findings include:

Women's Dorm 1 & 2

1. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. There were wood studs used to support suspended ceiling grid - construction type doesn't permit the use of combustible members in the rated roof/ceiling assembly - located in roof/ceiling assembly above office #20.

b. There were no ceiling fire dampers in mechanical inlets/outlets throughout the facility - alternative to ceiling fire damper assemblies are missing or in disrepair at duct penetrations of ceiling assembly - located in resident rooms and areas near office #20.

c. There were no fire protective enclosures for recessed light fixtures in office #20.

d. There were holes in the rated roof/ceiling assembly of office #20.

e. There was a wedge under door to room #13.

f. There was a wedge under door to janitor's closet - located beside nurse's station.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Men's Dorm 1, 2, & 3

2. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. There were no fire protective enclosures for recessed light fixtures - located throughout facility.

b. There were no ceiling fire dampers at duct penetrations of rated roof/ceiling assembly - alternative to ceiling fire dampers, at time of construction, is missing or in disrepair.

c. There was a combustible, wood deck, structure in the required means of egress path - located at the exit discharge on westside of building.

d. There was a wedge under door to room #10.

e. Dutch door to discharge room was not equipped with self-closing device on upper leaf - doors are not arranged to close and latch as a unit.

f. The duct penetrations of required smoke barrier were not equipped with smoke dampers - located at main mechanical room.

g. There were no air handler shutdown switches located at supervised station.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Acute Care Unit

3. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. There were chairs stored in the means of egress near the nurse's station - located near area reserved as a sitting area.

b. There were travel distances exceeding fifty feet to exit access doors from interior courtyard

c. The exit discharge path extends near an embankment with no guardrail between deep and sloped area adjacent to sidewalk - located near room B108. The slope perpendicular to the direction of travel exceeds 1 in 48.

d. There was inadequate exit directional signage for courtyard near dayroom - direction to exit was not obvious beyond exit access gate from courtyard.

e. There were holes in the enclosing wall of gas-fired water heater room - room contains main sprinkler riser.

f. There was no electrical supervision of main sprinkler control valves located in outside valve pit.

g. There are kickstops mounted on cross corridor smoke barrier doors - located near rooms B116/B102 & C101.

h. Duct smoke detector sampling tubes are covered with dust - detectors shall be maintained in accordance with manufacturer's installation instructions.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Pharmacy & Clinic (PNC)

4. Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard was non-compliant, specific findings include:

a. The fire wall between the business occupancy and health care section was incomplete due to holes in barrier - holes are located above ceiling in room #13.

b. There were holes in the rated roof/ceiling assembly of panel room - located at rear lobby.

c. Gas fired water heater room was not one hour enclosed or equipped with sprinkler

d. There was no air handler shutdown switches located at a supervised station.

e. There were high temperature, exposed element, portable space heaters observed in the following rooms:
1. room PC 116
2. room PC 110
3. under desk in laboratory office

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on policy review, medical record reviews and staff interviews, the treatment center staff failed to ensure short and long term goals had expected completion dates for 14 of 15 sampled patients with treatment plans (Patients 21, 4, 7, 3, 9, 6, 11, 15, 1, 24, 8, 12, 13, 14).

The findings include:

Review on 02/23/2017 of the facility's policy, "INTERDISCIPLINARY TREATMENT TEAM COMPOSITION AND RESPONSIBILITIES" effective 04/15/2009 revealed, "PURPOSE [sic] To describe the organization, responsibilities, and scheduling of the Interdisciplinary Treatment Team on the Acute Rehabilitation Services, (ARS) unit and the Acute Care Unit ...PROCEDURE I. ...II. ...C. ..2. The goals of the Treatment Plan shall be derived from the ongoing assessments of the above-mentioned services. The interventions identified to achieve these goals shall focus on actions on the part of the patient that may be observed, measured, and documented, in order to ensure that satisfactory progress is being made. ..."

1. Closed medical record review on 02/24/2017 revealed on 11/14/2016, Patient #21, a 24 year-old was involuntarily committed to the treatment center related to mental illness and dangerous to self or others. Review revealed an admitting diagnosis of Acute Psychosis and Substance Abuse. Review of the treatment plan revealed between 11/14/2016 to 11/17/2016, two short term goals were established. Review revealed the goals did not have an expected completion date.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan. Interview revealed the Clinical Director was unable to provide a rationale as to "why" the short and long term goals had no expected completion date.


2. Open medical record review on 02/22/2017 revealed on 02/02/2017, Patient #4, a 41 year-old was voluntarily admitted to the treatment center for Alcohol Dependency and Post Traumatic Stress Disorder (PTSD). Review of the treatment plan revealed from 02/02/2017 through 02/09/2017, fourteen short term goals and seven long term goals were established. Review revealed the goals did not have an expected completion date.

Interview on 02/22/2017 at 1350 with the Program Manager revealed short and long term goals were determined to be ongoing until discharge from the treatment center.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan. Interview revealed the Clinical Director was unable to provide a rationale as to "why" the short and long term goals had no expected completion date.

3. Open medical record review on 02/22/2017 revealed on 02/03/2017, Patient #7, a 45 year-old was voluntarily admitted to the treatment center for Alcohol/Substance Abuse and Depressive Disorder. Review of the treatment plan revealed from 02/03/2017 through 02/17/2017, seventeen short term goal and eight long term goals were established. Review revealed the goals did not have an expected completion date.

Interview on 02/23/2017 at 1430 revealed Nursing Supervisor #1 acknowledge the short and long term goals did not have an expected completion date. Interview revealed the Nursing Supervisor was unable to provide a reason as to "why" the goals did not have an expected completion date.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan. Interview revealed the Clinical Director was unable to provide a rationale as to "why" the short and long term goals had no expected completion date.





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4. Open medical record review on 02/22/2017 revealed on 01/25/2017 Patient #3, a 30 year old male was involuntarily committed to treatment center related to periodic suicidal thoughts requiring 1:1 observation. Review revealed admitting diagnosis of chemical dependence and anxiety. Review of the treatment plan dated 02/10/2017 and 02/20/2017 revealed 4 short term goals without target dates of completion.

Interview with AS #1 on 02/23/2017 at 0915 revealed treatment plan was not complete. Further interview revealed no reason on why dates were not on the treatment plan.

5. Open medical record review on 02/22/2017 revealed on 02/16/2017 Patient #9, a 46 year old male was admitted to facility after parole violation for alcohol use. Review revealed admitting diagnosis of chemical dependency and unspecified depression disorder. Review of the treatment plan dated 02/16/2017 and 02/20/2017 revealed 4 short term goals with 2 goals without target dates.

Interview with AS #1 on 02/23/2017 at 0915 revealed treatment plan was not complete. Further interview revealed reason why dates were not on the treatment plan.


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6. Open medical record review on 02/22/2017 for Patient #6, revealed a 36 year old female patient was admitted to the detox unit on 02/04/2017 with diagnoses including Alcohol Withdrawal Syndrome, Alcohol Use Disorder, Nicotine Use Disorder and Unspecified Depressive Disorder. Review of the patient's treatment plan revealed forms with short and long term goals established on 02/04/2017. Review revealed no documented target date or time frames for expected achievement of the goals, and no updates or documentation of measurement of the short and long term goals.

Interview on 02/24/2017 at 0833 with LPC #1 (Licensed Practicing Counselor), revealed the date of completion for the short and long term goals was "the date of discharge." The interview revealed fourteen days was the average length of stay. "Fourteen days is short ... and it's [the goals] still going to be something they [patients] work towards when they leave, that's the hope anyways."

7. Open medical record review on 02/22/2017 for Patient #11, revealed a 52 year old female was admitted on 02/13/2017 with diagnoses including Stimulate Use Disorder (Cocaine); ADHD (Attention Deficit Hyperactivity Disorder), Major Depressive Disorder, and Nicotine Use Disorder. The patient was transferred to this facility for continuation of treatment after spending time in a nearby detox facility. Review of the patient's treatment plan revealed forms with short and long term goals established on 02/13/2017. Review revealed no documented target date or time frames for expected achievement of the goals, and no updates or documentation of measurement of the short and long term goals.

Interview on 02/24/2017 at 0833 with LPC #1, revealed the date of completion for the short and long terms goals was "the date of discharge." The interview revealed fourteen days was the average length of stay. "Fourteen days is short ... and it's [the goals] still going to be something they [patients] work towards when they leave, that's the hope anyways."

8. Closed medical record review on 02/22/2017 for Patient #15, revealed a 40 year old male admitted to the facility on 01/26/2017 with diagnoses including Alcohol Withdrawal Syndrome, Alcohol Use Disorder, Nicotine Use Disorder, Cannabis Use Disorder, and Questionable Mood Disorder (Depression versus Anxiety). Review of the patient's treatment plan revealed forms with short and long term goals established on 01/26/2017. Review revealed no documented target date or time frames for expected achievement of the goals, and no updates or documentation of measurement of the short and long term goals.

Interview on 02/24/2017 at 0833 with LPC #1, revealed the date of completion for the short and long terms goals was "the date of discharge." The interview revealed fourteen days was the average length of stay. "Fourteen days is short ... and it's [the goals] still going to be something they [patients] work towards when they leave, that's the hope anyways."

Attempted interview on 02/23/2017 with LCSW,LCASA (Licensed Clinical Social Worker,Licensed Clinical Addiction Specialist) #1 revealed she [LCSW,LCASA #1]was out on medical leave and was not available for interview.



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9. Open medical record review on 02/23/2017 revealed Patient # 1, a 32 year-old female involuntarily committed to the treatment center on 1/31/2017 due to mental illness and behaviors of being dangerous to self or others. Review of the treatment plan revealed short and long term goals were established on 02/03/2017. Review revealed the goals did not have an expected completion date.

Interview on 02/23/2017 at 1045 with the Program Manager revealed treatment plans are considered to be ongoing during admission. Interview revealed goals were targeted to be reached or completed by the expected discharge date.


10. Open medical review on 02/24/2016 revealed Patient # 24 , a 51 year-old female voluntarily admitted to the treatment center on 02/07/2017. Review of the treatment plan revealed short and long term goals were established on 02/07/2017. Review revealed the goals did not have an expected completion date.

Interview on 02/23/2017 at 1045 with the Program Manager revealed treatment plans are considered to be ongoing during admission. Interview revealed goals were targeted to be reached or completed by the expected discharge date.



36956

11. Open medical record review on 02/22/2017 revealed Patient #8, a 61 year-old male was voluntarily admitted to the Acute Care Unit (ACU) of the treatment center for detoxification on 02/11/2017 with a diagnosis of alcohol dependency uncomplicated. Review of the treatment plan revealed one of the nine goals were established on 02/11/2017. The long and short term goals were established on the following dates 02/12/2017 and 02/13/2017. Review revealed the short and long term goals did not have an expected completion date.

Interview on 02/23/2017 at 1130 with a Counselor revealed the goals are set and interventions performed. Interview revealed upon discharge the goals will be completed and documented.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

12. Open medical record review on 02/23/2017 revealed Patient #12, a 29 year-old female was voluntarily admitted to the ACU of the treatment center for detoxification on 02/02/2017. Review revealed short term and long term goals were established. Further review of the three problem sheets treatment plan revealed short and long term goals were established on the following dates 02/02/2017, 02/03/2017, 02/05/2017, 02/13/2017, 02/14/2017 and 02/15/2017. Further review revealed the short term and long term goals did not have an expected completion date.

Interview on 02/23/2017 at 1130 with a Counselor revealed the goals are set and interventions performed. Interview revealed upon discharge the goals will be completed and documented.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

13. Closed medical record review on 02/23/2017 revealed Patient #13, a 23 year-old female was voluntarily admitted to the Adult Rehabilitation Services (ARS) unit on 02/06/2016 at 0907. Review revealed the treatment plan was initiated on 02/06/2017 and included four identifiable problems. Review revealed the short and long term goals and interventions did not have an expected completion date.

Interview on 02/23/2017 at 1130 with a Counselor revealed the goals are set and interventions performed. Interview revealed upon discharge the goals will be completed and documented.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

14. Closed medical record review on 02/23/2017 revealed Patient #14, a 57 year-old female was voluntarily admitted to the ARS unit of the treatment center on 02/06/2017 at 0846 with a diagnosis of other stimulant dependence uncomplicated. Review of the treatment plan revealed short term goals were established on 02/06/2017, 02/07/2017 and 02/08/2017 and included three identifiable problems. Review of the three treatment plan sheets revealed short term goals did not have an expected completion date. Review revealed no available documentation of established long term goals.

Interview on 02/23/2017 at 1130 with a Counselor revealed the goals are set and interventions performed. Interview revealed upon discharge the goals will be completed and documented.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

Based on review of policy, medical records, and staff interviews, the facility staff failed to ensure the frequency for treatment plan modalities were documented in specific, measurable terms for 14 of 14 sample patients
(Patients 8, 12, 13, 14, 1, 24, 6, 11,15, 3, 9, 21, 4 and 7).

Review on 02/23/2017 of the facility's policy "INTERDISCIPLINARY TREATMENT TEAM COMPOSITION AND RESPONSIBILITIES" effective 04/15/2009 revealed "...PURPOSE...To describe the organization, responsibilities, and scheduling the Interdisciplinary Treatment Team on the Acute Rehabilitation Services (ARS) unit and the Acute Care Unit (ACU.)...PROCEDURE...II. Responsibilities of the Interdisciplinary Treatment Team...2. The goals of the Treatment Plan shall be derived from the ongoing assessments of the above-mentioned services. The interventions identified to achieve these goals shall focus on actions on the part of the patient that may be observed, measured, and documented, in order to ensure that satisfactory progress is being made...."

1. Open medical record review on 02/22/2017 revealed Patient #8, a 61 year-old male was voluntarily admitted to ACU of the treatment center for detoxification on 02/11/2017 with a diagnosis of alcohol dependency uncomplicated. Review of the treatment plan modalities portion of the treatment plan dated 02/14/2017 revealed for "Case Management/Care Coordinator..." and "Individual/ Family Therapy:" Modality Type "Frequency" was documented as "As Needed". Review revealed as needed did not define a specific frequency for the Modality Type.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

2. Open medical record review on 02/23/2017 revealed Patient #12, a 29 year-old female was voluntarily admitted to the ACU of the treatment center for detoxification on 02/02/2017. Review revealed three problems were identified as part of the treatment plan. Review of the treatment plan modalities portion of the treatment plan dated 02/04/2017 revealed for "Case Management/Care Coordinator..." and "Individual/ Family Therapy:"Modality Type "Frequency" was documented "As Needed". Review revealed as needed did not define a specific frequency for the Modality Type.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

3. Closed medical record review on 02/23/2017 revealed Patient #13, a 23 year-old female was voluntarily admitted to the ARS unit on 02/06/2016. Review revealed the treatment plan was initiated on 02/06/2017 and included four identifiable problems. Review of the treatment plan modalities portion of the treatment plan dated 02/14/2017 revealed for "Case Management/Care Coordinator..." Modality Type "Frequency" was documented "As Needed". Review revealed as needed did not define a specific frequency for the Modality Type.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.

4. Closed medical record review on 02/23/2017 revealed Patient #14, a 57 year-old female was voluntarily admitted to the ARS unit of the treatment center on 02/06/2017 at 0846 with a diagnosis of other stimulant dependence uncomplicated. Review of the treatment plan revealed short goals were established on 02/06/2017, 02/07/2017 and 02/08/2017 and included three identifiable problems. Review of the treatment plan modalities portion of the treatment plan dated 02/06/2017 revealed for "Case Management/Care Coordinator..." and "Individual/ Family Therapy:" Modality Type "Frequency" was documented "As Needed". Review revealed as needed did not define a specific frequency for the Modality Type.

Interview on 02/24/2017 at 0845 with the Director of Nursing (DON) revealed the treatment plan was not meeting policy.


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5. Open medical record review on 02/23/2017 revealed Patient # 1, a 32 year-old female was involuntarily committed to the treatment center on 1/31/2017 due to mental illness and behaviors of being dangerous to self or others. Review of the treatment plan modalities portion of the treatment plan dated 02/03/2017 revealed "Type of Modality" the "Case Management/Care Coordinator to discuss specific discharge issues" the "Frequency" was documented "As Needed". Review revealed "As Needed" does not define a specific frequency for the modality.

Interview on 02/23/2017 at 1340 with LPC #1 (Licensed Practicing Counselor) revealed discharge and therapy needs for each patient were unique and would be addressed at some point during ongoing treatment. Interview revealed specific times were not identified due to unknown needs of the patient at the time of creating the treatment plan. Interview revealed the treatment modalities could be modified and changed depending on the needs of the patient. Interview revealed she understands the modalities need to be specific and individualized.

6. Open medical review on 02/24/2016 revealed Patient # 24, a 51 year-old female was voluntarily admitted to the treatment center on 02/07/2017. Review of the treatment plan modalities portion of the treatment plan dated 02/07/2017 revealed under "Type of Modality" the "Case Management/Care Coordinator to discuss specific discharge issues" and "Individual/ Family Therapy" the "Frequency" was documented "As Needed". Review revealed "As Needed" does not define a specific frequency for the modality.


Interview on 02/23/2017 at 1340 with LPC #1 revealed discharge and therapy needs for each patient were unique and would be addressed at some point during ongoing treatment. Interview revealed specific times were not identified due to unknown needs of the patient at the time of creating the treatment plan. Interview revealed the treatment modalities could be modified and changed depending on the needs of the patient. Interview revealed she understands the modalities need to be specific and individualized.





34963

7. Open medical record review on 02/22/2017 for Patient # 6, revealed a 36 year old female patient was admitted to the detox unit on 02/04/2017 with diagnoses including Alcohol Withdrawal Syndrome, Alcohol Use Disorder, Nicotine Use Disorder and Unspecified Depressive Disorder. The patient was transferred to the girl's dorm on the ARS side of campus for continuation of treatment on 02/20/2017. Review of the "TREATMENT PLAN MODALITIES" section of the patient's treatment plan, dated 02/17/2017, revealed three columns: 1) Type of Modality, 2) Frequency, and 3) Responsible staff - Name & Discipline. The frequency for the modalities "Case Management/Care Coordinator to address specific discharge issues" and "Individual/Family Therapy," was documented as "As Needed" by the LPC. Review revealed the frequency was not documented in specific, measurable terms.

Interview on 02/24/2017 at 0833 with LPC #1, revealed group sessions were five times a week "because we always meet five times a week." For individual counseling "we write 'as needed,' but we meet with them [patients] one on one at least once a week." The interview revealed "The case management is always 'as needed,' it depends on what kind of case management ..." The interview revealed the LPC was taught to put "as needed" for the frequency of the Case Management/Care Coordinator and individual/Family Therapy modalities.

8. Open medical record review on 02/22/2017 for Patient #11, revealed a 52 year old female patient was admitted on 02/13/2017 with diagnoses including Stimulate Use Disorder (Cocaine); severe, ADHD (Attention Deficit Hyperactivity Disorder), combined type, severe; Major Depressive Disorder, recurrent; and Nicotine Use Disorder, mild. The patient was transferred to this facility for continuation of treatment after spending time in a nearby detox facility. Review of the "TREATMENT PLAN MODALITIES" section of the patient's treatment plan, dated 02/13/2017, revealed three columns: 1) Type of Modality, 2) Frequency, and 3) Responsible staff - Name & Discipline. The frequency for the modalities "Case Management/Care Coordinator to address specific discharge issues" and "Individual/Family Therapy," was documented as "As Needed" by the LPC. Review revealed the frequency was not documented in specific, measurable terms.

Interview on 02/24/2017 at 0833 with LPC #1, revealed group sessions were five times a week "because we always meet five times a week." For individual counseling "we write 'as needed,' but we meet with them [patients] one on one at least once a week." The interview revealed "The case management is always 'as needed,' it depends on what kind of case management ..." The interview revealed the LPC was taught to put "as needed" for the frequency of the Case Management/Care Coordinator and individual/Family Therapy modalities.

9. Closed medical record review on 02/22/2017 for Patient #15, revealed a 40 year old male patient was admitted to the facility on 01/26/2017 with diagnoses including Alcohol Withdrawal Syndrome, Alcohol Use Disorder, Nicotine Use Disorder, Cannabis Use Disorder, and Questionable Mood Disorder (Depression versus Anxiety). Review of the "TREATMENT PLAN MODALITIES" section of the patient's treatment plan, dated 01/27/2017, revealed three columns: 1) Type of Modality, 2) Frequency, and 3) Responsible staff - Name & Discipline. The frequency for the modalities "Case Management/Care Coordinator to address specific discharge issues" and "Individual/Family Therapy," was documented as "As Needed" by the LCSW, LCASA (Licensed Clinical Social Worker, Licensed Clinical Addiction Specialist) #1. Review revealed the frequency was not documented in specific, measurable terms.

Interview on 02/24/2017 at 0833 with LPC #1, revealed group sessions were five times a week "because we always meet five times a week." For individual counseling "we write 'as needed,' but we meet with them [patients] one on one at least once a week." The interview revealed "The case management is always 'as needed,' it depends on what kind of case management ..." The interview revealed the LPC was taught to put "as needed" for the frequency of the Case Management/Care Coordinator and individual/Family Therapy modalities.

Attempted interview on 02/23/2017 with LCSW, LCASA #1 revealed the staff member was out on medical leave and was not available for interview.


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10. Open medical record review revealed Patient #3, a 30 year-old male was involuntarily committed to treatment center related to periodic suicidal thoughts requiring 1:1 observation. Review revealed admitting diagnosis of chemical dependence and anxiety. Review of the treatment plan modalities portion of the treatment plan dated 01/26/2017 revealed "As needed" documented by "Case Management/Care Coordinator ..." and "Individual/Family Therapy." Review revealed "as needed" did not define a specific frequency for the modality type.

Interview with AS #1 on 02/23/2017 at 0915 revealed treatment plan was not complete.

11. Open medical record review revealed on 02/16/2017 Patient #9, a 46 year-old male was admitted to facility after parole violation for alcohol use. Review revealed admitting diagnosis of chemical dependency and unspecified depression disorder. Review of the treatment plan modalities portion of the treatment plan dated 02/20/2017 revealed "As needed" documented by "Case Management/Care Coordinator ..." and "Individual/Family Therapy." Review revealed "as needed" did not define a specific frequency for the modality type.

Interview with AS #1 on 02/23/2017 at 0915 revealed treatment plan was not complete.










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12. Closed medical record review on 02/24/2017 revealed on 11/14/2016, Patient #21, a 24 year-old was involuntarily committed to the treatment center related to mental illness and dangerous to self or others. Review revealed an admitting diagnosis of Acute Psychosis and Substance Abuse. Review of the treatment plan modalities portion of the treatment plan dated 01/26/2017 revealed "As needed" documented by "Case Management/Care Coordinator ..." and "Individual/Family Therapy." Review revealed as needed did not define a specific frequency for the modality.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan.

13. Open medical record review on 02/22/2017 revealed on 02/02/2017, Patient #4, a 41 year-old was voluntarily admitted to the treatment center for Alcohol Dependency and Post Traumatic Stress Disorder (PTSD). Review of the treatment plan modalities portion of the treatment plan dated 01/26/2017 revealed "As needed" documented by "Case Management/Care Coordinator ..." and "Individual/Family Therapy." Review revealed as needed did not define a specific frequency for the modality.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan.

14. Open medical record review on 02/22/2017 revealed on 02/03/2017, Patient #7, a 45 year-old was voluntarily admitted to the treatment center for Alcohol/Substance Abuse and Depressive Disorder. Review of the treatment plan modalities portion of the treatment plan dated 01/26/2017 revealed "As needed" documented by "Case Management/Care Coordinator ..." and "Individual/Family Therapy." Review revealed as needed did not define a specific frequency for the modality.

Interview on 02/24/2017 at 1050 revealed the Clinical Director was made aware, date unknown, of the concerns with the treatment plan.