HospitalInspections.org

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure 26 patient beds did not pose a risk as a ligature point on Ward 4, Ward 5, Ward 6, and Ward 7.

Findings include:

Review on November 5, 2018, of facility policy, "Patient Bill Of Rights,"no date listed, revealed "You have a right to be treated with dignity and respect. ...11. You have the right to receive care in a safe setting. ..."

Review on November 5, 2018, of facility policy, "Assessment and Reduction of Suicide and Ligature Risk," effective date May 2018, revealed "Policy Statement: ...directs that all patients have a right to receive care in a safe setting. As one component of providing care in a safe setting, hospitals must identify patients at risk for intentional harm to self, identify environmental safety risks for such patients including but not limited to ligature risk, and communicate the results of any risk assessment and what interventions have been ordered. This policy describes how CSSH will provide these requirements. ..."

Observation tour of Ward 4 on November 5, 2018, revealed the special care room and patient rooms 14-3, 14-4, and 14-5 had electric beds with side rails with open loopable points.

Observation tour of Ward 5 on November 5, 2018, revealed two special care rooms, and patient rooms 14-11 and 14-14 had electric beds with side rails and open loopable points.

Interview with EMP14 on November 5, 2018, confirmed these electric beds with ligature points pose a risk for a person with suicidal thoughts.

Observation tour of Ward 6 on November 5, 2018, revealed the special care room, and patient rooms 15-2, 15-3, 15-4, 15-5, 15-6 had electric beds with side rails with open loopable points.

Observation tour of Ward 7 on November 5, 2018, revealed patient rooms 16-3, 16-4, 16-12, 16-14, 16-16 had electric beds with side rails with open loopable points.

Interview with EMP15 on November 5, 2018, confirmed these electric beds with ligature points pose a risk for a person with suicidal thoughts.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure all hair was restrained by hair nets and jewelry was limited for staff working in the dietary department; the facility failed to ensure foods added to the menu were reflected on the food temperature log; the facility failed to ensure food temperatures were recorded and monitored for safety; and, the facility failed to ensure food substitutions on the menu were reviewed and approved by the Dietician.

Findings include:

1) Review on November 6, 2018, of the facility's "Infection Control Program Dietary Department Personal Requirements for Personnel" policy, last reviewed October 2018 revealed "... Food service employees are defined as an individual whose occupations involve the preparation or serving of food or beverages. Examples are food service workers and cooks. ... 1. Hair Covering: a.) All female employees must wear hairnets that completely cover the hair at all times in all food service areas. b.) All male employees with short hair must wear disposable caps or white clean caps. c.) Male employees with over-the-ear or longer hair must wear hairnets that completely cover the hair at all times in the food service areas. d.) male employees with beards must wear "beard bags" at all times in the food services areas. ... 5. Limit jewelry to: a. wedding rings b. pierced earrings if close to earlobe c. watches worn by supervisory personnel or staff not involved in food preparation or handling. ..."

Observation on November 6, 2018, of EMP4, EMP5 and EMP6 revealed these employees preparing and distributing food for patient consumption without all hair restrained in the hair net.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP4, EMP5 and EMP6 were preparing and distributing food for patient consumption without all hair restrained in the hair net.

Observation on November 6, 2018, of EMP7, EMP8 and EMP9 revealed these employees preparing and distributing food for patient consumption with long necklaces hanging from around their necks.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP7, EMP8 and EMP9 were preparing and distributing food for patient consumption with long necklaces hanging from around their necks. EMP1 revealed necklaces are not to be worn by dietary employees when working in the dietary department.

Observation on November 6, 2018, of EMP10 and EMP11 revealed these employees preparing and distributing food for patient consumption without all facial hair restrained in the facial covering.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP10 and EMP11 were preparing and distributing food for patient consumption without all facial hair restrained in the facial covering.

2) A request was made of EMP1, EMP2 and EMP3 for the facility's policy, procedure or guideline for dietary staff to reference when adding new menu items to the patient menu. None was provided.

Review on November 6, 2018, of the Diet Spreadsheet Week at a glance revealed dietary served pork sausage for breakfast on February 28, March 3 and 17, 2018 and pork-ham on March 10 and 13, 2018.

There was no documentation on the Tray Temperature Monitoring Form indicating dietary staff tested the temperature of the pork sausage or the pork-ham to ensure these food products were a safe temperature for serving to the patients.

Interview with EMP1 on November 6, 2018, at approximately 10:50 AM revealed the dietary department added pork sausage and pork-ham to the menu, the Food Temperature Monitoring Form was not modified to reflect the addition of these new food items and there was no documentation dietary staff tested the temperature of these food items to ensure they were at a safe temperature for serving to the patients.

3) Review on November 6, 2018, of the "Food Serving Temperature" policy, dated August 30, 2017, revealed "Policy Statement: The Dietary Department of Clarks Summit State Hospital will serve food at a safe temperature within designated guidelines. Purpose: To ensure all food, hot and cold, is served and consumed at a safe temperature. Responsibility: Food Service Workers, Food Service Supervisors and Dietitians ..."

Review on November 6, 2018, of the "Holding Foods for Service Hot-Holding Guidelines" no review date, revealed "1. Keep "hot foods hot." Hot-holding equipment must keep foods at 140 degrees F.[Fahrenheit] or higher. 2. Measure internal temperatures every 2 hours and record. 3. Stir at regular intervals. 4. Keep foods covered. 5. Discard food after 4 hours if not held at or above 140 degrees F. 6. Never mix fresh food with food being held. 7. Prepare food in small batches. 8. Never use hot-holding equipment to reheat foods. 9. Store utensils properly and use long handled sanitized utensils. 10. Change utensils every 4 hours. 11. Practice good personal hygiene."

Review on November 6, 2018, of the "Cold-Holding Guidelines" no date, revealed "1. Keep "cold foods cold." Cold-holding equipment must keep food at 40 degrees F or lower. 2. Do not store food directly on ice. 3. Keep foods covered. 4. Change utensils every 4 hours. 5. Store utensils properly and use long handled sanitized utensils. 6. Practice good personal hygiene."

Review on November 6, 2018, of the facility's "Tray Temperature Monitoring Form" no review date, revealed columns for dietary staff to document temperatures at 6:45 A.M. and 7:45 A.M. for Breakfast food items and temperatures of Juice 40 , Milk 40 , Cereal 175, Eggs 145, Hot beverages 150 and Toast; at 10:45 A.M. and 11:45 A.M. for Lunch food items and temperatures of Soup 180, Regular Meat 180, Ground Meat 180, Pureed Meat 180, Potato/Starch 160, Vegetable 160, Chopped Vegetable 160, Ground Vegetable 160, Milk 40, Hot Beverage 150 and Dessert 40; and at 3:30 P.M. and 5:00 P.M. for Supper food items and temperatures of Soup 180, Regular Meat 180, Ground Meat 180, Pureed Meat 180, Potato/Starch 160, Vegetable 160, Chopped Vegetable 160, Ground Vegetable 160, Milk 40, Hot Beverage 150 and Dessert 40. There is documentation on this form indicating Food tested, in compliance with appearance and temperature and a space for the Food Service Supervisor to sign.

The Tray Temperature Monitoring Form for January 1, 24 and 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for January 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages for breakfast; soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch and supper.

The Tray Temperature Monitoring Form for February 23, 24, 25, 26 and 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for February 28, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

The Tray Temperature Monitoring Form for March 10 and 13, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for July 13, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

The Tray Temperature Monitoring Form for August 11, 12, 15 and 16, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for September 8, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for October 5 and 26, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at approximately 11:45 AM confirmed there were no documented food temperatures taken on the hot and cold foods on the tray line prior to distribution to patients to ensure the foods were at the proper temperature.

4) Review on November 6, 2018, of the facility's "Menu Substitutions" policy, dated June 29, 2017, revealed "Procedure: 1. Menus are planned by the Director of Dietetic Services II and the Clinical Dietitian Manager. The menus consist of two cycles: Fall/Winter and Spring/Summer. Each consists of a four week cycle menu. 2. When unexpected changes to the menu are necessary, they must be approved by the Director or the Clinical Dietitian Manager. In their absence, the Clinical Dietitian or the Food Manager may approve the change. Menu changes may occur due to delivery problems, equipment breakdown, emergency situations, etc. 3. Once menu changes are approved, they are to be recorded in the dietary office using the designated form showing proper approval and reason for the change."

Review on November 6, 2018, of the Menu Substitution List revealed the following food substitutions were not approved by the Director or the Clinical Dietitian Manager:
November 6, 2017, dietary substituted zucchini for peas.
November 13, 2017, dietary substituted tomato salad for cucumber salad.
January 4, 2018, dietary substituted salisbury steak for roast beef and ham for bologna.
January 20, 2018, peas and carrots for broccoli.
January 30, 2018, salisbury steak for pork roast.
February 7, 2018, zucchini for carrots.
February 20, 2018, scrambled eggs for omelets; donuts for coffee cake and lactaid milk for soy milk.
March 19, 2018, three bean salad for coleslaw.
May 23, 2018, three bean salad for cabbage.
October 30, 2018, broccoli salad for coleslaw.

There was no documentation the food substitutions were approved by the Director or the Clinical Dietitian Manager

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at approximately 11:50 AM confirmed the above food substitutions were not approved by the Director or the Clinical Dietitian Manager.

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

I. Provide a psychiatric evaluation for one (1) of eight (8) active sample patients (A1). Therefore, there is no documented information to justify the diagnosis and the planned treatment. In addition, there is no baseline psychiatric data from which the treatment team can assess the Patient's change in status through the course of treatment. (Refer to B110)

II. Address in the Master Treatment Plans (MTPs), those problems that were identified in the Admission Psychiatric Assessment for four (4) of eight (8) active sample patients. (A2, A4, A5, and A7) In addition, the MTPs were not modified, except to change the timeframe, even when behavioral patient events occurred. Specifically, the MTPs did not identify patient problems that necessitated hospitalization and did not identify individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of patients. Failure to address the individual needs of patients has the potential to prolong progress toward discharge and negatively impact each patient's recovery. (Refer to B118)

III. Provide scheduled programming to address the individual needs of patients. Specifically, it was determined that eight (8) of eight (8) active patients reviewed (A1, A2, A3, A4, A5, A6, A7, and A8) lacked an active individualized therapeutic program for significant periods of time during their hospital stay. Active selected patient schedules showed a lack of or absence of weekend and/or evening scheduled activities. Many of the unscheduled recreational/leisure type activities during those time periods were offered in the Recreational Building which was separate from the hospital wards. Only those patients with the required privilege level could leave the units to attend the activities. Four (4) of the eight (8) active patients, (A4, A5, A7, and A8) did not have a privilege level to leave the unit. One (1) of the eight (8) patients (A6) had privileges but refused to leave the unit to attend activities. On-unit activities were largely unscheduled and were selected by the patients if desired. This lack of therapeutic treatment, designed to meet the individualized needs of the patients, results in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125 l)

lV. Ensure that active treatment measures, such as group and/or individual treatment, were provided for one (1) of eight (8) active sample patients (A4) who was unwilling, or not motivated, to attend or participate in active treatment groups. The MTP for this patient failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the patient's improvement. (Refer to B125 ll)

Based on record review and interview, the facility failed to provide a psychiatric evaluation for one (1) of eight (8) active sample patients (A1). Therefore, there is no documented information to justify the diagnosis and the planned treatment. In addition, there is no baseline psychiatric data from which the treatment team can assess the patient's change in status through the course of treatment.

Findings Include:

A. Record review:

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note, dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part, we will postpone it at this time, the formal assessment and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours" ... "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the hospital failed to ensure that the psychiatric evaluation in the medical records included specific information of chronic and/or continuous non-psychiatric disorders in the medical history of one (1) of eight (8) randomly selected active patients (Patient A1). This results in failure to assess the impact of an acute or chronic medical condition on current psychiatric presentation.

Findings Include:

A. Record Review:

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note, dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient, while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part. We will postpone it at this time the formal assessment and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours." ... "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based record review and interview, the facility failed to ensure that one (1) of eight (8) sample patients (A1) received a psychiatric evaluation containing a mental status examination that is descriptive, with documentation to support the patient's diagnosis and establish a baseline sufficient for comparison of treatment outcomes. In addition, the absence of detailed mental status evaluations makes objective patient assessment data unavailable to the treatment team and results in treatment staff being unable to accurately assess ongoing patient mental status and progress in treatment, potentially impacting adversely on decisions regarding patient care, treatment and disposition.

Findings Include:

A. Record Review

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note, dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient, while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part, we will postpone it at this time the formal assessment and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours." ... "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the facility failed to provide a psychiatric evaluation detailing the onset of illness and the circumstances leading to admission for one (1) of eight (8) active sample patients (A1). This results in the inability to clearly assess patient's prior level of functioning and can result in inappropriate treatment goals and activities.

Findings Include:

A. Record Review

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note, dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part, we will postpone the formal assessment at this time and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours." ... "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the facility failed to provide a problem statement describing attitudes and behavior that required hospitalization one (1) of the eight (8) sample patients (A1). This results in failure to provide the treatment team with a description of target behaviors that would be helpful in designing an individualized treatment plan.

Findings Include:

A. Record Review

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note, dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part. We will postpone the formal assessment at this time and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours.".. "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for one (1) of eight (8) sample patients (A1). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. This results in the failure to identify important organic conditions and patient problems, compromising effective treatment by establishing inappropriate goals and treatment modalities.

Findings Include:

A. Record Review

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient, while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part, we will postpone it at this time, the formal assessment and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours." ... "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for one (1) of eight (8) sample patients (A1). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings Include:

A. Record Review

1. Patient A1, admitted on 7/24/18, did not have an Admission Psychiatric Assessment in his/her medical record. Although there was an Admission Psychiatric Assessment Note dated 7/26/18 at 11:30 a.m., it contained only the following information:

"An attempt was made on two occasions to sit down with patient for [his/her] Admission Psychiatric Assessment. Both times, the patient while cooperative initially and briefly, became somewhat anxious and asked if the assessment could be postponed to a later date. Clinically I believe to reduce any type of anxiety or agitation on patient's part. We will postpone the formal assessment at this time, and will continue to try and achieve an extended formal Admission Psychiatric Assessment."

2. Review of the facility policy, Clarks Summit State Hospital Policy Memorandum NUMBER: A-080 and titled, "Admission assessment/Treatment and Annual Update," (Page 2 Section A, Psychiatry) states: "The psychiatrist conducting the psychiatric admission interview will complete the psychiatric portion of Initial Annual Comprehensive Assessment and place in the chart within twenty-four (24) hours.".. "The dictated psychiatric assessment shall be dictated, transcribed, authenticated and on the patient chart within sixty (60) hours of admission."

B. Interview

1. During an interview on 8/15/18 at 1:00 p.m., Physician 3 acknowledged that an Admission Psychiatric Assessment had not been completed on this patient.

2. During an interview on 8/16/18 at 9:15 p.m., the Chief Executive Officer concurred that an Admission Psychiatric Assessment should be in the Medical Record in keeping with hospital policy.

3. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the need for an Admission Psychiatric Assessment on the patient's medical record.

Based on record review and interview, the facility failed to address in the Master Treatment Plans (MTPs), those problems that were identified in the Admission Psychiatric Assessment for four (4) of eight (8) active sample patients. (A2, A4, A5, and A7). In addition, the MTPs were not modified, except to change the timeframe, even when behavioral patient events occurred. Specifically, the MTPs did not identify patient problems that necessitated hospitalization and did not identify individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of patients. Failure to address the individual needs of patients has the potential to prolong progress toward discharge and negatively impact each patient's recovery.

Findings Include:

A. Record Review

1. Patient A2 was admitted on 1/30/18. The Admission Psychiatric Assessment, dated 1/31/18, stated that the patient was admitted from prison where s/he was incarcerated for assault. Patient A2 had become non-compliant with medications which led to the aggressive behavior. The MTP, dated 2/1/18, listed the only problem as, "[Patient] has a problem with delusions AEB [As Evidenced By] a belief that [s/he] is being poisoned." The Long-Term Goal (LTG) for this problem was: "[Patient] will gain a better understanding of [his/her] mental health issues AEB no refusals of prescribed medication and program attendance x [times] 90 days." The Short-Term Goal for this problem was: "[Patient] will gain a better understanding of [his/her] mental health issues AEB no medication refusals and no more than three (3) program refusals per week x 30 days." These goals stayed in effect until 5/1/18 (three (3)months) when they were modified with the LTG time extended from 90 days to 12 months and the STG changed from " ...no more than three program refusals x 30 days" to " ...no more than two (2) program refusals x three (3) months." These modified goals stayed in effect until 7/24/18 (almost three (3) months) when they were again modified with the LTG language eliminating the reference to medication refusals and leaving only " ...no refusals of scheduled treatment programs x 12 months" and the STG changed from " ...no more than two (2) program refusals x three (3) months" to " ...no more than one refusal x three (3) months." The goals remain the same as of 8/16/18.

Review of the Interdisciplinary Progress Notes revealed that on 7/11/18 at 4:20p.m., Patient A2 "Verbally threatened peer who jumped up and struck pt. (patient) several times ...Haldol [anti-psychotic medication] 20 mg [milligrams] IM [Intramuscular] stat [now] for agitation. Privilege reduced to Level 1 [ward restriction.]" There was no change in the treatment plan to address the aggressive behavior.

Review of the Interdisciplinary Progress Notes revealed that on 7/13/18 at 6:40 p.m., Patient A2 " ...pulled the speaker off the wall in the hallway." Patient A2 was " ...given Thorazine (anti- psychotic medication) 200 mg po (by mouth) stat." There was no change in the treatment plan to address the aggressive behavior.

Review of the Interdisciplinary Progress Notes revealed that Patient A2 was not making progress towards his/her treatment goals. Those notes included: Therapeutic Recreation Note dated 7/20/18 stated, "[Patient] has made no progress on [his/her] treatment goal of gaining a better understanding of [his/her] mental health issues ..." The monthly Nursing Progress Notes dated 7/22/18 stated, "[Patient] has made no progress toward [his/her] treatment team goal of understanding [his/her] mental illness." The Psychology Progress Note dated 7/23/18 stated, "[Patient] has not made progress toward [his/her] treatment team goal of gaining a better understanding of [his/her] mental health issues." There was no change in the treatment plan to address the failure to meet the treatment team goal of understanding [his/her] mental illness nor were any additional goals or interventions added.

Review of the facility policy, "Individualized Comprehensive Treatment Plan," dated October 28, 2015, Number A-057, stated that treatment plan reviews are conducted on day ten (10) and at least every 30 days after and " ...whenever there is a special need."

In interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director agreed that the goal did not represent the problem that resulted in Patient A2 being hospitalized. The Clinical Medical Director further stated that he thought the staff did not like to write and therefore there was a lack of comprehensive documentation.

2. Patient A4 was admitted on 5/9/18. The Admission Psychiatric Assessment dated 5/9/18, stated that the patient was hospitalized due to increasing physical aggression towards staff at the personal care home where s/he was living. The patient had been non-compliant with medications and thought that s/he was being poisoned.

The MTP, dated 5/11/18, listed four problems that included: "[Patient] is psychotic ...," "[Patient] is manic ...," "[Patient] has no insight into [his/her] mental illness," and "[Patient] does not take care of [his/her] hygiene ..." There were two (2) LTGs addressed in the MTP.

The LTG for the problem, "Psychotic," was, "[Patient] will demonstrate an ability to deal/cope with psychosis AEB participating in all of [his/her] scheduled programs and interacting with others in a reality based manner when talking about ward related issues 100% of the time; x 90 days." The STG was stated, "[Patient] will demonstrate an ability to deal/cope with psychosis AEB participating in 50% of [his/her] scheduled programs x 30 days." This goal was dated 5/11/18. On 8/13/18, the MTP was updated. The LTG remained the same but the STG was changed to, "[Patient] will demonstrate an ability to deal/cope with psychosis AEB participating at least in [his/her] 1:1 scheduled programs; x 30 days."

The LTG for the problem, "...has no insight into [his/her] mental illness," was, "[Patient] will demonstrate better insight/understanding of treatment AEB taking [his/her] prescribed medication and listing three (3) reasons why it is important to take [his/her] medication regularly; x 90 days." The STG was stated, "[Patient] will demonstrate better insight into [his/her] mental illness AEB taking [his/her] prescribed medication without needing to be prompted [sic] and listing one (1) reason why it is important to take [his/her] medication regularly; x 30 days." On 8/13/18, the MTP was updated. The STG was changed to, "[Patient] will demonstrate better insight into her mental illness AEB taking her prescribed medication without needing to be prompted; x 30 days.

Although Patient A4 remained psychotic and delusional (not reality-based and having false, fixed beliefs) for greater than three (3) months since admission and was refusing all groups and 1:1 interactions, there was no indication on the MTP that the treatment team was considering other therapeutic approaches to dealing with Patient A4.

Review of the Interdisciplinary Progress Notes revealed that Patient A4 was not making progress towards his/her treatment goals. Those notes included: Weekly Nursing Note dated 6/18/18 stated, "[S/he] does not attend [his/her] programs. Staff will continue to monitor and support." The Social Services Note dated 6/26/18 stated, "[Patient] continues to refuse medication, labs and programs." The Social Services Note dated 7/3/18 stated, "[S/he] continues to refuse medication, programs and speaking with this writer." The Weekly Nursing Note dated 7/3/18 stated, "Does not interact with peers. Hyperverbal with irrational behavior." The Weekly Nursing Note dated 7/9/18 stated, "[Patient] refuses to shower most days. [S/he] does not attend programs." The Monthly Nursing Note dated 7/16/18 stated, "[Patient] has not made any progress towards [his/her] goal that [he/she] will demonstrate an ability to deal/cope with Psychosis AEB not attending any programs x last 30 days even after encouragement given." The Psychiatrist Note dated 7/28/18 stated, "[S/he] doesn't participate in programs." Social Services Monthly Note dated 8/13/18 stated, [Patient] continues to refuse medications and programs daily."

Interview

During interview on 8/14/18 at 2:15 p.m., Physician 1 stated that Patient A4 did not participate in treatment which included his/her scheduled 1:1 (patient meeting alone with staff member).

During interview on 8/15/18 at 9:30 a.m., RN 4 was asked why the expectations listed in Patient A4's STGs had been reduced. She stated that Patient A4 could not meet the expectations so they lowered the expectations.

3. Patient A5 was admitted on 3/27/18. The Admission Psychiatric Assessment, dated 3/30/18, noted a history of attempting to buy a gun to kill him/herself. (S/he) also had a history of being cognitively impaired. The Admission Psychiatric Assessment stated, "The patient is currently able to contract for safely. [S/he] does not want to kill [him/herself] while at the hospital." The assessment listed only a diagnosis of "Schizoaffective Disorder, Bipolar Type" and did not reference the cognitive deficits.

The Master Treatment Plan, dated 3/29/18, listed the following five problems:

1. "[Patient] has a history of mood disorder, depression, and mania. [S/he] became very depressed, hopeless, and helpless; [S/he] tried to commit suicide by trying to purchase a gun; [S/he] wanted to put it in [his/her] mouth and pull the trigger. [Patient] has a history of previous suicide attempts-the last time [s/he] was admitted here [sic] [s/he] had tried to hang [him/herself], but the cord broke. Stressors are the [patient] stopped taking [his/her] medication - [patient] states that [s/he] couldn't get [his/her] Access card. [Patient] states that [s/he] was diagnosed with Bipolar disorder in the past, but [s/he] could not give a clear history of mania, other than not sleeping and being energetic."

2. "[Patient] became psychotic - [s/he] started hearing voices, 'the voices told me to kill myself. They made disparaging comments about me.' [S/he] also was feeling paranoid. [Patient] has a history of psychosis. [Patient] carries a diagnosis of Schizoaffective Disorder, bipolar type."

3. "[Patient] has a history of reading and mathematics disorder. [Patient] dropped out in 11th grade. [Patient] may have borderline intellectual functioning at baseline. No testing is currently available."

4. [Patient] is cognitively impaired. [S/he] scored 21/30 on the MMSE [Mini Mental Status Examination] while here in 2015. On [his/her] most recent test, [he/she] scored 19/30. This is abnormal even for [his/her] 11th grade education. [Patient] lost points on attention, the exact date and on recall. [S/he] could not copy the two intersecting pentagons [sic], in the past [his/her] clock drawing was disorganized. [His/her] clock drawing now was impaired, [s/he] could not put in the correct time."

5. "[Patient] has poor insight into [his/her] mental illness. [S/he] stopped taking [his/her] medication; [s/he] decompensated."

The Long-Term Goal [LTG] listed on the MTP was "[Patient] will be safe as evidenced by committing to using coping strategies for any suicidal urges, naming/identifying three (3) coping strategies [he/she] can utilize x three (3) months". The Short-Term Goal [STG] was "[Patient] will be safe as evidenced by committing to using coping strategies, name 1 coping strategy for any suicidal thought x one (1) month."

Further review of treatment plan updates revealed that this patient's goal had not changed since admission. There were no goals related to non-compliance of medications (couldn't get Access card) or cognitive impairment.

Interviews

During an interview on 8/15/18 at1:50 p.m., SW 2 indicated that this patient also had a diagnosis of Multiple Myeloma and a diagnostic workup for this was in progress. The patient was being sent for a second medical opinion and a determination was being made as to whether the patient was competent to make medical decisions. [S/he] acknowledged that this problem was not listed on the MTP.

During interview with the Medical Director on 8/16/18 at 12:00 p.m., confirmed that the problem of Multiple Myeloma was not yet on the MTP.

During interview on 8/16/18 at 9:30 a.m., RN 7 was asked to query the patient's treatment team regarding the absence of the Medical Problem on the MTP. She returned at 1:00 p.m. and confirmed that the problem was not yet on the MTP and that work on the problem was "in process."

4. Patient A7 was admitted on 7/18/18. The Admission Psychiatric Assessment, dated 7/24/18 listed the diagnosis as "Bipolar Depression, mixed state severe without psychotic features and a past diagnosis of Cognitive Disorder NOS." The Assessment further noted a history of multiple psychiatric hospitalizations with Electroconvulsive Therapy treatments at age 20 and 25, and immediately prior to admission. S/he had a history of a brain mengioma (brain tumor) removal with residual cognitive deficits. The patient stated on admission, "that [s/he] would never do anything to harm [him/herself] 'because of [his/her] family'."

The Master Treatment Plan dated, 7/20/18, listed the following problem statement: "[S/he] has a problem with depression as evidenced by suicidal ideation and inability to care for self." The patient's only listed Short Term Goal [STG] was "[Patient] will verbalize [his/her] thoughts and feelings to staff as evidenced by talking to staff about [his/her] thoughts and feelings at least once daily x one (1) month." There was not a STG related to the Cognitive Disorder or inability to care for self.

Patient Interview

During an interview on 8/14/16 at 11:00 a.m., the patient indicated that (s/he) was having difficulties with memory, was unable to drive, and had difficulties making the bed and cooking. (S/he] was not oriented to day or date.

Staff Interview

During an interview on 8/14/18 at 1:45 p.m., Physician 3 discussed with the surveyor the patient's memory loss and the etiology of the loss being unclear. He did agree that the memory loss probably needed to be on the treatment plan.

During an interview on 8/16/18 at 9:15 a.m., the Chief Executive Officer agreed that memory loss should be on the treatment plan.

During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred that the memory loss should have been addressed as part of the treatment plan.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that included individualized patient-related goals. The patient goals were not related to the identified problems and were not always connected to the stated, measureable outcome for five (5) of eight (8) active sample patients (A1, A2, A4, A5, and A8). This deficient practice hampers the ability of the treatment team to provide goal directed treatment that addresses the needs of individual patients which can impact negatively on the recovery process.

Findings Include:

A. Record Review

1. Patient A1 had identified on the MTP, dated 7/27/18, the problem, "[Patient] decompensates becoming paranoid, disorganized and making threats toward others. [S/he] expresses delusions that [s/he] is an undercover agent for the government leading to agitation/verbal threats." The short-term goal (STG) for this problem was, "[Patient] will demonstrate a reduction in paranoid delusions as evidenced by (AEB) no more than one statement daily that [s/he] is an undercover Fed Ex (Federal Express) agent and Navy Seal x three (3) months." Attaching a measurable outcome (no more than one (1) statement daily) to an unmeasurable goal (reduction in paranoid delusions) does not meet the intent of this standard.

2. Patient A2 had identified on the MTP, dated 2/1/18, the problem, "[Patient] has a problem with delusions [false, fixed beliefs] AEB by [sic] a belief that [s/he] is being poisoned." The unrelated STG for this problem was, "[Patient] will gain a better understanding of [his/her] mental health issues AEB no medication refusals and no more than three (3) program refusals per week x 30 days." Attaching a measurable outcome (medication refusal and program attendance) to an unmeasurable goal (will gain a better understanding of mental health issues) does not meet the intent of this standard.

3. Patient A4 had identified on the MTP, dated 5/11/18, the problem, "[Patient] is psychotic ..." The STG for this problem was, "[Patient] will demonstrate an ability to deal/cope with psychosis AEB participating in 50% of [his/her] scheduled programs; x 30 days." Attaching a measurable outcome (participating in 50% of [his/her] scheduled programs) to an unmeasurable goal (will demonstrate an ability to deal/cope with psychosis) does not meet the intent of this standard.

4. Patient A5 had identified on the MTP, dated 3/29/18, the problem, "[Patient] has a history of mood disorder, depression, and mania. [S/he] became very depressed, hopeless, and helpless; [S/he] tried to commit suicide by trying to purchase a gun; [s/he] wanted to put it in [his/her] mouth and pull the trigger. [Patient] has a history of previous suicide attempts-the last time (s/he) was admitted here [sic] [s/he] had tried to hang [him/herself], but the cord broke. Stressors are the [patient] stopped taking [his/her] medication - [patient] states that [s/he] couldn't get [his/her] Access card. [Patient] states that [s/he] was diagnosed with Bipolar disorder in the past, but [s/he] could not give a clear history of mania, other than not sleeping and being energetic." The STG for this problem was, "[Patient] will be safe AEB committing to using coping strategies for any suicidal urges by naming/identifying three (3) coping strategies [s/he] can utilize x three (3) months." Attaching a measurable outcome (naming/identifying three (3) coping strategies) to an unmeasurable goal (will be safe) does not meet the intent of this standard.

5. Patient A6 had identified on the MTP, dated 6/22/18, the problem, "Psychosis AEB [Patient] has psychosis [s/he] experiences delusions, behaviors are disorganized. Prior to admission [Patient] was paranoid that others meant [him/her] harm including neighbors [s/he] believed were peeking on [him/her]. [Patient] makes eye puckering during conversations and is a poor historian." The unrelated STG for this problem was, "[Patient] will comply with recommended treatment AEB take medicine as prescribed and state three (3) positive effects of medications x three (3) months." Attaching a measurable outcome ((three) 3 coping strategies) to an unmeasurable goal (will comply with recommended treatment) does not meet the intent of the standard.

B. Interview

1. During interview on 8/16/18 at 10:30 a.m., the Director of Nursing agreed that the STGs presented were not related to the identified patient problems.

2. During interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director agreed that the presented STGs were stated in such a way that they did not always relate to the identified problems. In addition, he agreed that the AEB statements, although measurable, did not always relate to the goal statement.

Based on record review, observation and interview, the facility failed to:

I. Provide scheduled programming to address the individual needs of patients. Specifically, it was determined that eight (8) of eight (8) active patients reviewed (A1, A2, A3, A4, A5, A6, A7, and A8) lacked an active individualized therapeutic program for significant periods of time during their hospital stay. Active selected patient schedules showed a lack of or absence of weekend and/or evening scheduled activities. Many of the unscheduled recreational/leisure type activities during those time periods were offered in the Recreational Building which was separate from the hospital wards. Only those patients with the required privilege level could leave the units to attend the activities. Four (4) of the eight (8) active patients, (A4, A5, A7, and A8) did not have a privilege level to leave the unit. One (1) of the eight (8) patients (A6) had privileges but refused to leave the unit to attend activities. On-unit activities were largely unscheduled and were selected by the patients if desired. This lack of therapeutic treatment, designed to meet the individualized needs of the patients, resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement.

II. Ensure that active treatment measures, such as group and/or individual treatment, were provided for one (1) of eight (8) active sample patients (A4) who was unwilling, or not motivated, to attend or participate in active treatment groups. The MTP for this patient failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the patient's improvement.

Findings Include:

A. Record Review

Patient schedules were provided to the surveyors by the Director of Activities. Review of those schedules revealed the following:

1. Patient A1's schedule showed one group offered on Monday morning and two groups offered Tuesday-Friday mornings. There were two groups offered in the afternoons, Monday-Friday. There were no groups scheduled after 3:00 p.m. on Monday-Thursday and one evening Singing Group offered on Friday. There were no groups scheduled on Saturday and one Medication Education group offered on Sunday.

2. Patient A2's schedule listed:
- on Monday, PEP (Patient Employment Program) On Grounds Cleaning (9:00-11:00 a.m.); Self-Management of Wellness (1:00-2:00 p.m.), Anger Management (2:00-3:00 p.m.);
- on Tuesday, Library (9:00-11:00 a.m.), On Grounds Cleaning PEP (1:00-3:00 p.m.), Sports Jam (6:00-8:00 p.m.);
- on Wednesday, On Grounds Cleaning PEP (9:00-11:00 a.m.), Drum Circle (1:00-2:00 p.m.), Stress Management (2:00-3:00 p.m.);
- on Thursday, On Grounds Cleaning PEP (9:00-11:00 a.m.), Introduction to Safe Computer Use (1:00-2:00 p.m.), Health Rhythms (2:00-3:00 p.m.);
- on Friday, Coping in the Kitchen (9:00-11:00 a.m.), Self-Directed Improvement (1:00-3:00 p.m.), Singing Away Stress (6:00-8:00 p.m.);
- on Saturday (no groups on schedule);
- on Sunday Nursing Med Ed (Medication Education) from 5:30-6:30 p.m.

During observation on Ward 3 on 8/14/18 from 1:15-1:40 p.m., Patient A2 was observed wearing blue gloves and holding a cleaning cloth. S/he was observed wiping down the walls and railings on the unit, often repeating where s/he had cleaned.

During interview on 8/14/18 at 1:15 p.m., RN 5 was asked by the surveyor to describe Patient A2's Patient Employment Program. RN 5 stated that patient A2 was usually out in the courtyard picking up trash but since it was raining s/he was working inside. When asked about supervision, RN 5 stated that Vocational Rehab checked on Patient A2 but were not with him/her for the entire two hours of work. Review of the schedule showed that Patient A2 spent eight (8) hours of his/her schedule doing cleaning work. When asked about the two hour "Self-Directed Improvement" group, RN 5 stated that this is when staff encourage the patient to do various tasks independently, like do their laundry or straighten their room or listen to music. The Library Group was described by RN 5 as a time when patients can go to the library and read, watch movies or get on the computer. Patient A2 was described by RN 5 as not having any interest in computers even though s/he is assigned to the Introduction to Safe Computer Use Group. The two hour Sports Jam Group was described as a time the patient could chose to play pool, bowl, play board games or play video games in the Recreation Hall.

3. Patient A3's schedule showed that no groups were offered after 3:00 p.m. There were no groups offered on Saturday and one (1) Medication Education Group offered on Sunday evening.

4. Patient A4 (who did not attend programming) had a schedule that did not include groups after 3:00 p.m. There were no evening groups on his/her schedule, only a Let's Get Organized Group on Saturday and Sunday morning and a Medication Education Group on Sunday morning. During interview on 8/15/18 at 2:30 p.m., RN 4 explained that the Let's Get Organized Group was when patients got up and did their morning hygiene and made up their bed and was not a therapeutic group.

5. Patient A5's schedule listed:
- on Monday, Music Appreciation (9:00-10:00 a.m.), Serenity of the Senses (10:00-11:00 a.m.), Reminiscence (1:00-2:00 p.m.);
- on Tuesday, Motivation (9:00-10:00 a.m.), Exercise/Hospital Resources (10:00-11:00 a.m.), Game On (1:00-2:00 p.m.), Attention and Concentration (2:00-3:00 p.m.);
- on Wednesday, Social Skills (9:00-10:00 a.m.), Cog-Rem [sic] (1:00-3:00 p.m.);
- on Thursday, Self-Directed Improvement (9:00-11:00 a.m.), Current Events (1:00-2:00 p.m.), Art for the Heart (2:00-3:00 p.m.);
- on Friday, Using Your Voice (9:00-10:00 a.m.), Moving Meditation (10:00-11:00 a.m.) , Creative Media (1:00-2:00 p.m.);
- on Saturday a one hour Med Ed group (Medication Education); listed for 3:00-11:00 p.m. [sic]; and
- on Sunday, Room Cleaning listed for eight hours.

Patient A5 had listed in [his/her] Master Treatment Plan problem statement, concerns about "Cognitive Impairment". There was no scheduled treatment to address that problem. There were no groups listed on the schedule Monday to Friday after 3:00 p.m. This patient did not have a level that permitted going to the Recreation Building.

During an interview on 8/14/18 at 1:30 p.m., this Patient was asked to leave the Reminiscence Group to allow the surveyor to do an interview. Upon asking the patient the name or content of the group, the response was "I don't know."

6. Patient A6's schedule listed: on Monday, Self-Directed Improvement from 9:00-11:00 a.m. During interview on 8/14/18, RN 5 explained that Self-Directed Improvement was not a staff-led group but a time when staff encourage the patient to do various tasks independently, like do their laundry or straighten their room or listen to music. The only group scheduled for Monday afternoon was Nail Care - Beautician (1:00-3:00 p.m.), followed by a singing group (6:00-8:00 p.m.); on Tuesday and Thursday there were no groups listed after 3:00 p.m. On Wednesday there was one group in the morning (Move to Independence), one (1) group in the afternoon (Music Appreciation), an hour (one (1)) of Self-Directed Improvement and another singing group from 6:00-8:00 p.m. On Thursday morning Patient A6 was again scheduled for Self-Directed Improvement from 9:00-11:00 a.m. There was no scheduled activities for Saturday and a Medication Education group and Recreation group scheduled for Sunday.

It should be noted that this patient has memory issues and no cognitive/ memory improvement offerings are listed on the schedule. This patient did not have a level that permitted going to the Recreation Building.

During an interview on 8/14/18 at 1:15 p.m. the surveyor asked the patient about weekends. (S/he) stated, "everyone looks at TV; no groups; kind of like time off."

7. Patient A7's schedule showed no therapeutic activities scheduled for this patient after 3:00 p.m. on Thursday and Friday. On Saturday there were no scheduled therapeutic activities. On Sunday, it showed Sunday Room Cleaning from 3:00-11:00 p.m.

This patient also refused to go on the off-Unit Activities and therefore those activities are unavailable to this patient.

8. Patient A8's schedule showed no scheduled activities after 3:00 p.m. on Monday, Tuesday, Wednesday and Thursday. There were no scheduled activities on Saturday and one hour of Medication Education scheduled for Sunday.

It should be noted that this patient does not have a level that would permit off unit activities and therefore cannot participate in some of the activities on his/her schedule. Information provided by the Activities Director for the period July 30-August 14, 2018, indicated that this patient attended only 39% of the activities offered.

B. Interview

1. During interview on 8/14/18 at 1:30 p.m., RN 6, when asked what patients do on the weekend, responded that the patients have "rest time." RN 6 further stated that although the staff encourage patients to straighten up their rooms or wash clothes on the weekend, many of them had rather sleep late or watch movies.

2. During an interview on 8/16/18 at 9:30 a.m. the Chief Executive officer concurred with the lack of patient activities on evenings and weekends.

3. During an interview on 8/16/18 at 10:30 a.m., the Director of Nursing indicated there was a set of 12 prepared activities that nurses could do with patients in the evening. However, she indicated there was not a record of these activities in the patients' medical record nor was the activity scheduled at a specific time or listed on the patients' schedules.

4. During an interview on 8/16/18 at 11:00 a.m., the Clinical Medical Director concurred with the findings of a lack of therapeutic activities on evenings and weekends.

III. Active Treatment Measures

A. Record Review

1. Patient A4 was admitted on 5/9/18. The Admission Psychiatric Assessment, dated 5/9//18, stated that the patient was hospitalized due to increasing physical aggression towards staff at the personal care home where s/he was living. The patient had been non-compliant with medications and thought that s/he was being poisoned.

2. Review of the Individual Schedule for Patient A4 revealed that s/he had 18 groups scheduled for the week. Review of the Program Attendance sheet for July 30-August 14, 2018 (provided by the Director of Activities on 6/15/18) showed that Patient A4 had attended only 12% of his/her scheduled groups during this timeframe.

3. Review of facility policy, "Clarks Summit State Hospital Policy Memorandum," dated October 2. 2015, Number A-057 stated, "Goals will be changed, and/or interventions modified, when clinical conditions indicate that a goal has not been met within the established time frame."

4. Review of Patient A4's Master Treatment Plan (MTP) dated 5/11/18 showed that the treatment plan had not substantially changed to address the patient's lack of attendance at scheduled groups. Since the patient was attending less than the 50% attendance goal, the STG was changed on 8/13/18 to state that s/he participate " ...at least in [his/her] 1:1 scheduled programs ..." There was nothing else on the MTP that indicated any other approach for alternative treatment was being considered.

5. Review of the Interdisciplinary Progress Notes revealed that Patient A4 was not making progress towards his/her treatment goals. Those notes included: Weekly Nursing Note dated 6/18/18 stated, "[S/he] does not attend [his/her] programs. Staff will continue to monitor and support." The Social Services Note dated 6/26/18 stated, "[Patient] continues to refuse medication, labs and programs." The Social Services Note dated 7/3/18 stated, "[S/he] continues to refuse medication, programs and speaking with this writer." The Weekly Nursing Note dated 7/3/18 stated, "Does not interact with peers. Hyperverbal with irrational behavior." The Weekly Nursing Note dated 7/9/18 stated, "[Patient] refuses to shower most days. [S/he] does not attend programs." The Monthly Nursing Note dated 7/16/18 stated, "[Patient] has not made any progress towards [his/her] goal that [he/she] will demonstrate an ability to deal/cope with Psychosis AEB not attending any programs x last 30 days even after encouragement given." The Psychiatrist Note dated 7/28/18 stated, "[S/he] doesn't participate in programs." Social Services Monthly Note dated 8/13/18 stated, [Patient] continues to refuse medications and programs daily."

B. Observation

1. During observation on Ward 3 on 8/14/18 from 1:00 p.m.-2:30 p.m., Patient A4 was observed walking back and forth in the hallway. S/he had a scheduled Psychology-Thinking Matters Group that was being held during this time.

2. During observation on Ward 3 on 8/15/18 from 9:00 a.m.-9:45 a.m., Patient A4 was observed sitting on the floor of the hallway during his/her scheduled group, Psychology-Emotional Regulation.

C. Interview

1. During interview on 8/14/18 at 2:15 p.m., Physician 1 stated that Patient A4 did not participate in treatment which included his/her scheduled 1:1.

2. During interview on 8/15/18 at 9:30 a.m., RN 4 was asked why the expectations listed in Patient A4's STGs had been reduced. She stated that Patient A4 could not meet the expectations so they lowered the expectations.

3. During interview on 8/15/18 at 9:45 a.m., Patient A4 stated that s/he did not go to groups because, "I am self-motivated and don't need to go."

I. Based on record review and interview, the Clinical Medical Director failed to ensure the provision of a psychiatric evaluation for one (1) of eight (8) active sample patients (A1). Therefore, there is no documented information to justify the diagnosis and the planned treatment. In addition, there is no baseline psychiatric data from which the treatment team can assess the patient's change in status through the course of treatment. (Refer to B110)

II. Based on record review and interview, the Clinical Medical Director failed to ensure that the Master Treatment Plans (MTPs) addressed those problems that were identified in the Admission Psychiatric Assessment for four (4) of eight (8) active sample patients (A2, A4, A5, and A7). In addition, the MTPs were not modified, except to change the timeframe, even when behavioral patient events occurred. Specifically, the MTPs did not identify patient problems that necessitated hospitalization and did not identify individualized needs based on identified problems. This failure results in treatment goals and interventions that are not based on the specific needs of patients. Failure to address the individual needs of patients has the potential to prolong progress toward discharge and negatively impact each patient's recovery. (Refer to B118).

III. Based on record review, observation and interview, the Clinical Medical Director failed to ensure:

A. The provision of scheduled programming to address the individual needs of patients. Specifically, it was determined that eight (8) of eight (8) active patients reviewed (A1, A2, A3, A4, A5, A6, A7, and A8) lacked an active individualized therapeutic program for significant periods of time during their hospital stay. Active selected patient schedules showed a lack of or absence of weekend and/or evening scheduled activities. Many of the unscheduled recreational/leisure type activities during those time periods were offered in the Recreational Building which was separate from the hospital wards. Only those patients with the required privilege level could leave the units to attend the activities. Four (4) of the eight (8) active patients, (A4, A5, A7, and A8) did not have a privilege level to leave the unit. One (1) of the eight (8) patients (A6) had privileges but refused to leave the unit to attend activities. On unit activities were largely unscheduled and were selected by the patients if desired. This lack of therapeutic treatment, designed to meet the individualized needs of the patients, resulted in these patients being hospitalized without all interventions for patient recovery being provided to them, potentially delaying their improvement. (Refer to B125 l)

B. Active treatment measures, such as group and/or individual treatment, were provided for one (1) of eight (8) active sample patients (A4) who was unwilling, or not motivated, to attend or participate in active treatment groups. The MTP for this patient failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying the patient's improvement. (Refer to B125)

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

1. That nursing activities held in the evenings were documented and included in the patients' medical records for eight (8) of eight (8) patients (A1, A2, A3, A4, A5, A6, A7, and A8). A lack of documentation regarding nursing groups in the medical record makes it difficult to determine if the groups actually occurred, which patients attended and the participation level of the patient.

2. That patient schedules were provided to the surveyors by the Director of Activities. Review of the schedules showed that the only nursing group offered during the week was the Medication Administration Group offered on the weekend. Review of Nursing Progress Notes failed to show that any nursing led groups occurred on the unit during the evening.

3. During an interview on 8/16/18 at 10:30 a.m., the Director of Nursing indicated there was a set of 12 prepared activities that nurses could do with patients in the evening. However, she indicated there was not a record of these activities in the patients' medical record nor was the activity scheduled at a specific time or listed on the patients' schedules. (Refer to B125)