HospitalInspections.org

Based on record review and interviews, the facility failed to document individualized short term measurable goals on the Master Treatment Plans (MTPs) of 9 of 11 (B1, B2, B3, C1, C2, D1, D2 and E1). The facility documented short term goals that were not measurable, and in some instances were generic duties. This failure results in Master Treatment Plans that do not identify expected outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment.

Findings include:

Record Review (MTP dates in parentheses)

1. Patient A1: The short term goal on the MTP (04/17/2011) was "pt will engage in unit based goals." The goal was generic, and not measurable.

2. Patient B1: The short term goal on MTP (04/12/2011) was "Patient will discuss discharge options and verbalize an understanding of the discharge plan." The goal was generic, and not measurable.

3. Patient B2: The short term goal on MTP (04/11/2011) was "The patient will maintain safety and self control with the assistance of staff." The goal was not measurable.

4. Patient B3: The short term goal on MTP (04/16/2011) was "Makes decisions regarding personal interests." The goal was not measurable.

5. Patient C1: The short term goal on MTP (04/16/2011) was "Practices alternative ways of coping with anxiety." The goal was not measurable.

6. Patient C2: The short term goal on MTP (04/18/2011) was "Patient will inform staff if/when he is having pain." The goal was not measurable.

7. Patient D1: The short term goal on MTP (04/12/2011) was "Patient/family will demonstrate willingness to resolve barriers to discharge." The goal was not measurable.

8. Patient D2: The short term goal on MTP (04/19/2011) was "Pt will be more inturned [sic] to his environment." This goal was not measureable.

9. Patient E1: The short term goal on MTP (04/18/2011) was "Develop and practice nightly sleep pattern with minimal interruptions." The goal was not measurable.

B. Staff Interviews

1. During an interview on 4/19/2011 at 2:15PM, the Director of Social Work stated "I understand and agree that it is too simplistic."

2. During an interview on 4/19/2011 at 2:45PM with the Director of Quality Assurance and the Director of Inpatient Services, both interviewees stated that they agreed with the above findings.

3. During an interview on 4/19/2011 at 3:15PM, the Medical Director agreed that short term goals on the treatment plans, as written, were "not in measurable terms."

Based on record review, and interviews, the facility failed to:

I. Develop Master Treatment Plans that clearly delineated interventions to address specific patient problems for 10 of 11 active sample patients (A1, A2, B2, B3, C1, C2, D1, D2, E1, and E2). The Master Treatment Plans did not list specific interventions/modalities or their frequency of use for the psychiatrist, nurse, social worker/case manager and/or activities therapists. Instead, the interventions were stated as generic discipline tasks without specifying the frequency of use for each intervention/modality. Failure to document specific treatment approaches on patients' Master Treatment Plans hampers staff's ability to assure consistency of treatment for each patient's problems.

II. Identify individualized physician modalities/interventions for 6 of 11 active sample patients (B1, B2, C1, D1, D2 and E1), based on assessed patient needs. There were no treatment modalities listed for physicians to perform on the Master Treatment Plans.

III. Identify treatment interventions to be provided by activities therapists on the Master Treatment Plans for 11 of 11 active sample patients (A1, A2, B1, B2, B3, C1, C2, D1, D2, E1 and E2).

These failures result in Master Treatment Plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

I. Generic discipline interventions:

A. Record Review

1. Patient (A1): The Master Treatment Plan developed on 4/17/2011 had the following listed interventions: "Encourage patient to attend appropriate groups to learn new coping methods and problem solving techniques. Collect and search belongings in accordance with hospital policy. Maintain precautions as necessary per hospital policy. Question directly regarding safety issues. Encourage patient to attend appropriate groups to learn new coping methods and problem solving techniques."

2. Patient (A2): The Master Treatment Plan developed on 4/11/2011 had the following listed interventions: "Nurse to assess precipitating/contributory factors. Nurse to monitor vital signs per physician order. Nurse to encourage verbalization of feelings, Nurse to provide quiet, calm environment. Nurse to instruct on use of relations exercises, tapes or books. Nurse to note duration, location, intensity of pain and document in medical record. Nurse to use pain scales before and after treatment for pain. Physician to prescribe medication at dosage and schedule prescribed noting effectiveness and side effects. Physician/Nurse to conduct patient education related to effects and side effects of medications. Obtain throat culture."

3. Patient (B2): The Master Treatment Plan developed on 4/11/2011 had the following listed interventions: "allow staff to collect and search belongings in accordance with hospital policy. Maintain precautions as necessary per hospital policy"; "using verbal skills to communicate feelings of unsafety [sic] and self destructiveness" ; "Nurse will teach patient signs/symptoms which need medical attention,; Nurse will administer inhalers as ordered by physician."; "Nurse will teach patient signs/symptoms which need medical attention. Physician/Nurse will evaluate medication to assist with symptoms including use of inhalers as needed"; "Social Worker/Case Manager will identify services that are accessible to the patient."

4. Patient (B3): The Master Treatment Plan developed on 4/16/2011 had the following listed interventions: "Assist client to grieve loss of use of chemical substances as a coping style,"; "Psychiatrist will prescribe and monitor medication daily to reduce the symptoms of mania"; "Nursing and/or Medical Staff will provide counseling sessions to help reality-orient the patient will respect to his/her grandiose ideas,7 [sic]"; "Social Worker/Case Manager will identify services that are accessible to the patient."

5. Patient (C1): The Master Treatment Plan developed on 4/16/2011 had the following listed interventions: "Encourage identification of unresolved family issues regarding dependency needs"; "meds supportive milieu [sic]."

6. Patient (C2): The Master Treatment Plan developed on 4/18/2011 had the following listed interventions: "Assist client to grieve loss of use of chemical substances as a coping style, Staff will confront client regarding attempts to be dependent, Encourage physical activity when restless behavior is observed, Assist client in evaluating resources and in learning how to get dependency needs met, Decrease inappropriate behavior by ignoring it and giving attention when not seeking it"; "Social Worker/Case Manager will identify services that are accessible to the patient."

7. Patient (D1): The Master Treatment Plan developed on 04/12/2011 has the following listed interventions: "Identify additional supports, Assess whether family will be able to care for patient with teaching support, Initiate contact with family to involve them in discharge planning"; "Collect and search belonging in accordance with hospital policy. Question directly regarding safety issue..."

8. Patient (D2): The Master Treatment Plan developed on 04/19/2011 had the following listed interventions: "medicate, educate, monitor"; "Social Worker/Case Manager will implement additional supports to assist patient in keeping appointments. Social Worker/Case Manager will identify services that are accessible to the patient."

9. Patient (E1): The Master Treatment Plan developed on 4/18/2011 had the following listed interventions: "Collect and search belongings in accordance with hospital policy. Maintain precautions as necessary per hospital policy. Question directly regarding safety issues. Encourage patient to attend appropriate groups to learn new coping methods and problem solving techniques"; "Facilitate ventilation of feelings by actively listening and reflecting. Staff will promote decision-making skills"; "Staff will encourage routine hour of sleep & discourage deviation from this schedule. Staff will establish with client nonstimulating [sic] bedtime rituals. Staff will prompt client to empty bladder before going to bed"; "Social Worker/Case Manager will identify services that are accessible to the patient."

10. Patient (E2): The Master Treatment Plan developed on 04/11/2011 had the following listed interventions: "Social Worker/Case Manager will identify services that are accessible to the patient."

B. Staff Interview

1. During an interview on 4/19/2011 at 2:15PM, the Director of Social Worker stated "I understand and agree that it is too simplistic."

2. During an interview on 4/19/2011 at 2:45PM with the Director of Quality Assurance and Director of Inpatient Services, both people stated "I agree with the findings."

II. Lack of documented physician interventions:

A. Record Review

1. Patient B1: The Master Treatment Plan developed on 04/12/2011 identified the patient problem as "Suicidal behavior as evidenced by specific behavior as evidenced by OD on medication." There were no physician interventions documented on the MTP.

2. Patient B2: The Master Treatment Plan developed on 04/11/2011 identified the patient problem as "Delusions or Auditory Hallucinations Commanding Self Harm." There were no physician interventions documented on MTP.

3. Patient C1: The Master Treatment Plan developed on 04/16/2011 identified the patient problem as "Excessive substance use." There were no physician interventions documented on MTP.

4. Patient D1: The Master Treatment Plan developed on 04/12/2011 identified the patient problem as "MR." There were no physician interventions documented on MTP.

5. Patient D2: The Master Treatment Plan developed on 04/19/2011 identified the patient problem as "Accompany paper reported that pt was disorganized, tangential." There were no physician interventions documented on MTP.

6. Patient E1: The Master Treatment Plan developed on 04/18/2011 identified the patient problem as "Patient C/O CAH to cut herself or kill herself." There were no physician interventions documented on MTP.

B. Staff Interview

During an interview on 4/19/2011 at 3:15PM, the Medical Director stated, "I agree with the findings."

III. Lack of documentation of Activities Therapy interventions:

A. Record Review

There were no activities therapist interventions documented for 11 of 11 active sample MTP patient records (A1, A2, B1, B2, B3, C1, C2, D1, D2, E1 and E2).

B. Staff Interview

During an interview on 4/19/2011 at 4:15PM with Clinical Supervisor for group clinicians (manages activities therapy at the facility), she stated, "We do not provide any interventions for the treatment plan. We provide group notes only."

Based on record review and interview, the facility failed to ensure that patient records accurately described a patient's treatment for one discharged patient (E3). More specifically, nursing staff members continued to provide group progress notes and nighttime bed checks notes on three occasions for patient E3 who had been discharged 2-3 days previously. This failure of accurate documentation places patients at risk for misinformation being provided to other staff and may lead to medical errors.

Findings include:

A. Record Review

1. Patient E3 was discharged from the hospital on 4/15/11.

2. A nursing progress note for Patient E3, dated 04/17/2011 on the night shift, stated "Patient observed throughout the night in bed with eyes closed and respirating [sic] regularly. Safe at all safety checks."

3. A nursing progress note for patient E3, dated 04/17/2011 on the day shift, stated in Comments: "TO GIVE PATIENTS THE OPPORTUNITY TO EVALUATE HOW THE DAY WENT AND TO MAKE APPROPRIATE ,REALISTIC GOAL FOR THE NEXT DAY." "Patient participated actively in the group."

4. A nursing progress note for patient E3, dated 04/18/2011 on the day shift, stated in Comments: "TO INCREASE PATIENTS' UNDERSTANDING OF TREATMENT AND THE HOSPITAL. The topic for this group was tolerance as a way to decrease anxiety and stress. Pts. were able to address realistic issues in their everyday life that made them feel anxious. They suggested possible ways to resolve it. The patient attended and participated well throughout the group."

B. Staff Interviews

1. During an interview on 4/18/11 at 3:15PM, the Director of Quality Assurance acknowledged that patient E3 had been discharged on 4/15/11, but that staff were still documenting that the patient was present in the hospital.

2. During an interview on 4/18/11 at 3:30PM, the Evening charge nurse on unit North Three verified that staff were still documenting in patient E3's record after the patient was discharged. She stated that she personally discharged the patient on 4/15/2011.

3. During an interview on 4/19/11 at 2:45PM, the Director of Inpatient Services agreed with findings and related it to problems with the Electronic Medical Record system.

Based on record review and interview, the facility failed to provide a discharge summary that summarized all of the treatment received in the hospital and the patient's response to treatment other than medication for 3 of 6 discharged patients whose records were reviewed (DC1, DC2, and DC6). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Record Review

1. Patient DC1: In a Discharge Summary dated 3/29/11, under the section for "Hospital Course," the physician noted the following: "Patient was detoxified with Librium protocol uneventfully. He continued on all meds he was taking in the community. Patient was advised to consider a ddart [sic] progrm [sic] which he refused as he had to go to court on June 4th. Partial hospital program at the Arbour with dorm placement was recommended. Though he agreed initially for this, later on declined wanting to be discharged. Patient showed no evidence of psychosis depression mania or suicidality during his tstay [sic] here. He was discharged with after care in place." There was no description of response to other treatment modalities during the hospitalization.

2. Patient DC2: In a Discharge Summary dated 2/15/11 under the section for "Hospital Course," the physician noted a recap of the patient ' s reason for admission, a problem list, an initial treatment plan and discussion of medication. The physician reported "Patient spending most of the time in bed." "Patient currently motivated for treatment." There was no discussion of what interventions were used to motivate this patient.

3. Patient DC6: In a Discharge Summary dated 2/1/11 under the section for "Hospital Course." The physician noted a recapitulation of medication trials during the patient's 5 week stay, there was no information about other modalities of treatment during the hospitalization.

B. Interview

In an interview on 4/19/11 at 3:15PM, the Medical Director was shown the records noted above and agreed with the findings.

Based on record review and interview, the facility failed to ensure that specific follow-up appointments were made prior to discharge and recorded in the discharge summaries of 4 of 6 discharge records reviewed (DC1, DC2, DC3 and DC4). The lack of definite follow-up appointments forces patients, who may still be compromised in their ability to act for themselves, to negotiate with agencies or offices. This may be difficult for them to do, and therefore they may fail to do it.

Findings include:

A. Record Review

1. Patient DC1: In a Discharge Summary dated 3/29/11, the psychiatrist noted under the section titled "Aftercare Plan" the following: "see the case management discharge plan." The case management discharge plan dated 3/29/11 did not identify any appointments for the patient.

2. Patient DC2: In a Discharge Summary dated 2/15/11, the psychiatrist noted under the section titled "Aftercare Plan" the following: "Patient is discharged today and will Continue [sic] outpatient psychopharmacology and psychotherapy. PCP follow up." No appointments were noted in the report.

3. Patient DC3: In a Discharge Summary dated 2/18/11, the psychiatrist noted under the section titled "Aftercare Plan" the following: "see the case management discharge plan." The case management discharge plan dated 2/18/11 did not identify any appointments for the patient.

4. Patient DC4: In a Discharge Summary dated 2/10/11, the psychiatrist noted under the section titled "Aftercare Plan" the following: "home. Individual and family therapy. Medication
supervision [sic]." No appointments were noted in the report.

B. Interview

In an interview on 4/19/11 at 3:15PM, after reviewing the records noted above, the Medical Director agreed with the findings and stated "Doctors should list appointments in the report."

Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 6 of 6 discharged patients whose records were reviewed (DC1, DC2, DC3, DC4, DC5 and DC6). This failure results in critical clinical information about the patient's psychiatric symptomatology and risk not being available to aftercare providers.

Findings include:

A. Record Review

1. Patient DC1: In a Discharge Summary dated 3/29/11, the treating psychiatrist noted the following recommendations: "Low Salt Diet." "Activities as tolerated."

2. Patient DC2: In a Discharge Summary dated 2/15/11, the treating psychiatrist noted the following recommendations: "Low fat, low cholesterol, low triglyceride diet." "Activities as tolerated."

3. Patient DC3: In a Discharge Summary dated 2/18/11, the treating psychiatrist noted the following recommendations: "Other Diet." "Activities as tolerated."

4. Patient DC4: In a Discharge Summary dated 2/10/11, the treating psychiatrist noted the following recommendations: "Regular Diet." "Activities as tolerated."

5. Patient DC5: In a Discharge Summary dated 2/17/11, the treating psychiatrist noted the following recommendations: "Regular Diet." "Activities as tolerated."

6. Patient DC6: In a Discharge Summary dated 2/1/11, the treating psychiatrist noted the following recommendations: "Regular Diet." "Activities as tolerated."

B. Interview

In an interview on 4/19/11 at 3:15PM, the Medical Director agreed with the findings and stated, "It's important for outpatient physicians to know our recommendations; this information should have been in the record."

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

I. Ensure that the electronic medical record used by the facility accurately recorded the time and date of physician entries into the Master Treatment Plan for 1 of 11 active sample patients (D2). The attending physician made an entry into the Master Treatment Plan on 4/15/11; yet the Master Treatment Plan was dated 4/19/11 when it was reviewed by the surveyors on 4/18/11. This failure can lead to misunderstandings and confusion between care givers, and it can result in medical records that do not accurately describe the course of treatment for patients.

Findings include:

A. Record Review

Patient D2: A Master Treatment Plan update dated 4/19/11 showed that the attending psychiatrist made additions to the plan to describe the plan of care for this patient. The surveyors reviewed this plan on 4/18/11 at 12p.m., one day before the date on the plan. There was a documentation on the bottom of the report that noted that the attending psychiatrist had made the entries on 4/15/11.

B. Interviews

1. In an interview on 4/20/11 at 9:15AM, the above attending psychiatrist stated that s/he was aware of the record discrepancy. S/he stated, "In order for me to make entries into the electronic record when I see the patient, I have to update the treatment plan first. The computer program automatically dates the report for the next time the treatment plan is due, so that's how it dated the plan ahead of time. It's a messed up system."

2. In an interview on 4/20/11 at 11:15AM, the Medical Director stated, "Our electronic medical record leaves a lot to be desired and has many glitches." He added that he wasn't sure how the problem can be corrected.

II. Ensure that facility staff documented individualized short term measurable goals on the Master Treatment Plans (MTPs) for 9 of 11 active sample patients (A1, B1, B2, B3, C1, C2, D1, D2 and E1). The facility documented short term goals that were not measurable, and in some instances, were generic duties.. This failure results in Master Treatment Plans do not identify expected outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment. (Refer to B121)

III. A. Ensure that facility staff develop Master Treatment Plans that clearly delineated interventions to address specific patient problems for 10 of 11 active sample patients (A1, A2, B2, B3, C1, C2, D1, D2, E1 and E2). The Master Treatment Plans did not list specific interventions/modalities or their frequency of use for the psychiatrist, nurse, social worker/case manager and/or activities therapists. Instead, the interventions were stated in generic discipline terms without specifying the frequency of use for each intervention/modality. Failure to document specific treatment approaches on patients' master treatment plans hampers staff's ability to assure consistency of treatment for each patient's problems. (Refer to B122-I)

III.B. Ensure that psychiatrists identified individualized physician modalities/interventions for 6 of 11 active sample patients (B1, B2, C1, D1, D2 and E1), based on patient needs. There were no treatment modalities listed on these patients' Master Treatment Plans for physicians to perform. (Refer to B122-II).

III.C. Ensure that the treatment team identified treatment interventions to be provided by activities therapists on the Master Treatment Plans for 11 of 11 active sample patients (A1, A2, B1, B2, B3, C1, C2, D1, D2, E1 and E2). (Refer to B122-III).

These failures result in Master Treatment Plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

IV. Ensure that physicians provided discharge summaries that included a review of all of the treatment received in the hospital and the patient's response to treatment for 3 of 6 discharged patients whose records were reviewed (DC1, DC2 and DC6). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

V. Ensure that physicians provided specific follow-up appointments, and that the appointments were made prior to discharge and recorded in the discharge summaries for 4 of 6 discharged patients whose records were reviewed (DC1, DC2, DC3 and DC4). The lack of definite follow-up appointments forces patients, who may still be compromised in their ability to act for themselves, to negotiate with agencies or offices. They may find this difficult to do, and therefore may fail to do so. (Refer to B134)

VI. Ensure that physicians provided discharge summaries that contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 6 of 6 discharged patients whose records were reviewed (DC1, DC2, DC3, DC4, DC5 and DC6). This failure results in critical clinical information about the patient's psychiatric symptomatology and risk not being available to aftercare providers. (Refer to B135)

Based on record review and interview, the Director of Nursing failed to ensure that nursing staff were following policy and procedure regarding discharge of patients. Specifically, the Director of Nursing failed to:

I. Ensure that nursing staff discontinued writing progress notes after discharge for 1 of 1 active sample patients (E3) who was added to the active sample for review of notes written post discharge. The post discharge notes included progress notes and observations completed two and three days after discharge; these were included as part of the record of documentations for the discharged patient.This failure results in lack of accuracy of nursing records,

Findings include:

A. Record Review

1. Patient E3 was discharged from the hospital on 4/15/11.

2. A nursing progress note for Patient E3, dated 04/17/2011 on the night shift, stated "Patient observed throughout the night in bed with eyes closed and respirating [sic] regularly. Safe at all safety checks."

3. A nursing progress note for patient E3, dated 04/17/2011 on the day shift, stated in Comments: "TO GIVE PATIENTS THE OPPORTUNITY TO EVALUATE HOW THE DAY WENT AND TO MAKE APPROPRIATE ,REALISTIC GOAL FOR THE NEXT DAY." "Patient participated actively in the group."

4. A nursing progress note for patient E3, dated 04/18/2011 on the day shift, stated in Comments: "TO INCREASE PATIENTS' UNDERSTANDING OF TREATMENT AND THE HOSPITAL. The topic for this group was tolerance as a way to decrease anxiety and stress. Pts. were able to address realistic issues in their everyday life that made them feel anxious. They suggested possible ways to resolve it. The patient attended and participated well throughout the group."

B. Staff Interviews

1. During an interview on 4/18/11 at 3:15PM, the Director of Quality Assurance acknowledged that patient E3 had been discharged on 4/15/11, but that staff were still documenting that the patient was present in the hospital.

2. During an interview on 4/18/11 at 3:30PM, the Evening charge nurse on unit North Three verified that staff were still documenting in patient E3's record after the patient was discharged. She stated that she personally discharged the patient on 4/15/2011.

3. During an interview on 4/19/11 at 2:45PM, the Director of Inpatient Services agreed with findings.

Based on observation, interviews and record review, the facility failed to define and provide therapeutic activities in the evenings and on weekends to meet the needs of patients. No Activity therapy modalities were listed on patient treatment plans. The facility utilized nursing staff (mainly Mental Health Workers [MHW]) to provide 1 hour of evening programming and 2 hours of weekend programming; there were no activity therapists in the facility in the evening or on weekends. Activities therapy staff did not supervise or monitor the effectiveness or quality of the programming provided by the MHWs. The average length of stay at the facility varies between 10 and 17 days. Failure to provide focused and supervised activities therapy in the evenings and weekends in a short stay facility denies patients important modes of treatment to maintain the benefits of hospitalization after discharge.

Findings include:

A. Observation

1. In an observation on 4/18/11, a Monday when the facility observed a state holiday and was on a weekend schedule), at 10:30AM in the Unit South 2 day room, a scheduled exercise group was in progress. The attending patients (9 total, including 2 active sample patients from the total census of 23) were gathered around a table, eating snack foods and watching the Boston Marathon on television. The group leader reported "On weekends, the patients decide what they want to do because they have choices; there's not a lot going on weekends so we try to keep them happy."

2. In observations on 4/18/11 at 1:15 PM, 3:00PM and 4:15PM on Unit South 3, the patients were observed standing or sitting around the nurse's station, lying in bed or engaged in self care activities. The unit schedule showed that patients had "Free art time" between lunch and dinner that day. No art supplies were observed to be available, and there were no MHWs engaging patients in art therapy during the observations.

B. Interviews

1. In an interview on 4/18/11 at 11:15AM, Patient B2 stated "It's pretty boring around here on weekends; we do watch a lot of TV and we get extra smoke breaks; that's what we look forward to." Patient B2 stated that evenings are similar.

2. In an interview on 4/18/11 at 3:10PM, Patient D2 was asked about weekend and evening activities and stated, "I want to go home; I could do nothing there as well."

3. In an interview on 4/19/11 at 4:00PM, The Group Services Coordinator (PsyD) stated that evening and weekend activities are provided by nursing staff, and that only two of the five units have an activity therapist that stays until 6 PM. She reported that there were no activities therapists on weekends. She acknowledged that she did not train, monitor or supervise the nursing staff assigned to the evening and weekend groups, and that she wasn't sure who oversaw the therapeutic content of the groups.

4. In an interview on 4/20/11 at 9:45AM, the Nurse Executive confirmed that nursing staff provide evening and weekend activity groups. She stated that the individual unit nurse managers are responsible for monitoring the groups for content and quality. She stated that there was one activities therapy group offered on weekends --a pet therapy session on each of the five units for 30 minutes at a time. She reported that the facility used to have more activities therapy time on weekends and evenings and wasn't sure why it stopped.

C. Record Review:

Since there were no activity therapy modalities listed on the treatment plans of any patients, it was not possible to determine what evening and weekend activity therapy services the patients needed, since the discipline had no input into any of the treatment plans. (Refer to B122 Part III.)