HospitalInspections.org

This condition is not met as evidenced by:

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

I. Ensure that the Master Treatment Plans (MTPs) included: Patient specific Problem statements were described in behavioral terms (B119), a substantiated diagnosis (B120), Short Term and Long-Term Goals (STG and LTGs) were written in observable, behavioral and measurable terms including an expected date of achievement. (B121)

II. Ensure that the therapeutic Interventions were patient/problem specific and included all treatment providers by name and discipline including frequency, modality and focus of the interventions. (B122 and B123)

III. Ensure that progress/treatment notes evidence and correspond to the identified treatment interventions and provided treatments including the progress/lack of progress a patient is making towards an identified goal/s. (B124)

IV. Provide active treatments including alternative treatments as needed for two (2) of eight (8) active sample patients. (B125)

Based on document review and staff interview, the facility failed to ensure that the Psychosocial Assessments for active sample patients, eight (8) of eight (8) patients (A1, A2, A3, A4, A5, A6, A7 and A8) included anticipated Social Work roles in treatment. As a result, critical patient psychosocial information necessary for informed treatment planning decisions was not available to the treatment teams.

Findings include:

A. Record Review

1. Patient A1 was admitted on 9/11/18. The Psychosocial Assessment completed on 9/12/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

2. Patient A2 was admitted on 11/17/18. The Psychosocial Assessment completed on 11/19/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

3. Patient A3 was admitted on 11/20/18. The Psychosocial Assessment completed on 11/21/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

4. Patient A4 was admitted on 9/11/18. The Psychosocial Assessment completed on 9/13/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

5. Patient A5 was admitted on 11/2318. The Psychosocial Assessment completed on 11/24/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

6. Patient A6 was admitted on 11/15/18. The Psychosocial Assessment completed on 11/16/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

7. Patient A7 was admitted on 9/12/18. The Psychosocial Assessment completed on 9/13/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.

8. Patient A8 was admitted on 11/15/18. The Psychosocial Assessment completed on 11/16/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment.


B. Staff interview:

In a meeting and review of the above deficiencies in the Psychosocial Assessments with the Director of Social Services on 11/27/18 at 2 p.m., he did not dispute the findings and stated "Thank you for sharing with me, we learn something."

Based on record review and staff interview the facility failed to ensure that the admission physical examinations included timely, screening neurological examinations for three (3) of eight (8) active sample patients. [A2, A4 and A5]. A failure to provide such screening neurological examinations compromises a patient's care and treatment including potentially prolonging hospitalization and discharge. As well, a failure to document current status precludes future comparative re-examinations to assess the patients' ongoing functioning.

Findings include:

A. Record Review:

1. Patient A2 was hospitalized on 11/17/18 and the admission physical examination completed on 11/18/18, as of the survey date 11/27/18 is not reviewed and signed by the Physician Assistant [PA] and/or the supervising physician per hospital policy. Also, the neurological examination states "Cranial Nerves: Unremarkable, Sensation: Unremarkable."

2. Patient A4 was hospitalized on 9/12/18 and the admission physical examination completed on 9/12/18 under "Neurologic, Cranial Nerves: Deep Tendon Reflexes: Sensation: "all left blank.

3. Patient A5 was hospitalized on 11/24/18 and the admission physical examination completed on 11/24/18 under "Neurologic, Cranial Nerves: Unremarkable, Deep Tendon Reflexes: [blank] Sensation: Unremarkable."

B. Policy review:

The hospital Medical Staff Rules and Regulations under History and Physical Examination on page 7 states, "The dictated Medical History and Physical Exam must be reviewed and signed within 24 hours by the originator."

C. Staff interview:

In a meeting with the Medical Director on 11/28/18 at 10:00 a.m. these deficiencies were reviewed and discussed. He agreed with the findings.

Based on record review, and interview, the facility failed to ensure that Master Treatment Plans (MTPs) included an inventory of individualized psychiatric disabilities (called problems by the facility) that were written in behavioral and descriptive terms for five (5) of eight (8) active sample patients (A1, A3, A6, A7, and A8). Specifically, the MTPs included problem statements with diagnoses, generalized statements, diagnostic terms, or psychiatric jargon rather than how each patient's psychiatric problem was manifested based on each patient's clinical assessment data. This failure can adversely affect clinical decision-making in formulating goal and intervention statements and results in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (9/13/18), A2 (11/20/18), A3 (11/22/18), A4 (9/13/18), A5 (11/26/18), A6 (11/16/18), A7 (9/13/18), and A8 (11/16/18). This review revealed the following deficiencies related to problem statements in the MTPs.

1. Patient A1 had the following deficient psychiatric problem statement: "Anxiety with Depression." This problem statement failed to describe how the patient precisely manifested the symptoms related to anxiety and depression. There were no descriptors of the patient's presenting psychiatric symptoms despite clinical assessments in the electronic medical record that identified these behaviors.

2. Patients A3 had the following deficient psychiatric problem statement "Suicidal ideation as evidenced by verbally mentioning suicidal thoughts without a plan." This statement was not individualized, and there was a failure to specify the content of thoughts or possible triggers for the thoughts manifested suicidal ideations.

3. Patient A6 had the following deficient psychiatric problem statement: "Suicidal ideation AEB (As Evidenced by) patient reported having SI (Suicidal Ideation)." This problem statement failed to describe how the patient precisely manifested the suicidal ideation(s) such as content, possible reasons for suicidal thoughts, and plan if any. There were no descriptors of the patient's presenting psychiatric symptoms despite clinical assessments in the electronic medical record that specified these behaviors.

4. Patient A7 had the following deficient psychiatric problem statements: "Sexual abuse of adolescent" and "Attachment disorder." These problem statements failed to describe how the patient precisely manifested the symptoms associated with sexual abuse and attachment disorder.

5. Patient A8 had the following deficient psychiatric problem statements: "Suicidal ideation" and "Aggression" These problem statements failed to describe how the patient precisely manifested suicidal ideation and aggressive behaviors. There were no descriptors of the patient's presenting psychiatric symptoms despite clinical assessments in the electronic medical record that specified these behaviors.

B. Interview

1. During an interview on 11/27/18 at 11:40 a.m. with RN3, a review of the MTPs showed that the problem statements were not descriptive of patient A6's presenting psychiatric symptoms of "suicidal ideation." She did dispute this finding and was able to locate a description of the patient's suicidal ideations and stated, "This should have been added to the problem."

2. In an interview on 11/27/18 at 1:20 p.m., the Director of Nursing (D.O.N), Director of Quality Improvement, and Program Directors for the Adolescent, Children and Adult Units did not dispute with findings that problems statements on some MTPs failed to include descriptive and behavioral information regarding presenting symptoms.

3. In an interview with the Medical Director on 11/28/18 at 10 a.m., a sample of these deficiencies were reviewed, and he concurred with the findings.

4. In an interview on 11/28/18 at 9:12 a.m., the D.O.N., acknowledged that RNs who initiated the MTPs inserted problem statements, but did not include how each patient manifested presenting symptoms.

Based on record review and staff interview the facility failed to identify a diagnosis that served as the primary focus for the treatment plans for eigth (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This practice compromises the staff's ability to deliver clinically focused treatment.

Findings include:

Master Treatment Plans (MTPs, dates in parenthesis) of patients' A1 (9/13/18), A2 (11/20/18), A3 (11/22/18), A4 (9/13/18), A5 (11/26/18), A6 (11/16/18), A7 (9/13/18) and A8 (11/16/18) did not have a substantiated diagnosis listed on the MTP.

Staff Interview:

In a meeting with the Director of Quality Assurance (DQA), Director of Nursing (DON), Assistant Director of Nursing (RN6), Program Managers 1, 2, and 3 on 11/27/18 at 1:25PM, and the Medical Director on 11/28/18 at 10:00 a.m., the above deficiencies were reviewed, and they did not dispute the findings.

Based on Record review and Staff interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short term (STG) and long term (LTG)goals stated in observable, measurable, and behavioral terms for eight (8) of eight (8) active patients (A1, A2, A3, A4, A5, A6, A7, and A8). As well, none of the goals had expected dates of achievement. Many of the goals were similar to many patients regardless of their presenting problems. This lack of patient specific goals hampers the treatment team's ability to assess changes in patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient's needs.

Findings include:

Medical Record Review:

1. Patient A1 admitted on 9/11/18 with a diagnosis of Schizophrenia with "obvious delusions of grandeur" had listed on MTP dated 9/13/18 for the Problem: "Anxiety with depression." the "STG/LTG: The case manager will provide discharge planning upon admission. Patient will at least know some coping skills to manage his/her depression and anxiety and be medication compliant.... into the community". These goals are staff expectations rather than addressing the specific problem.

2. Pt. A2 was hospitalized on 11/17/18 with a diagnosis of Bipolar Disorder, current episode depressed, severe, with psychotic features. The MTP dated 11/20/18 had for the Problem: "Bipolar disorder, current episode depressed, severe with psychotic features..." STG: "will maintain adequate nutrition, sleep and activity; as well as reality-based thinking for three consecutive days prior to discharge." LTG: "will be stabilized in the hospital and return to the community to complete outpatient treatment." These goals appear as staff expectations and are difficult to measure.

3. Pt. A3 was hospitalized on 11/20/18 with a diagnosis of Major Depressive Episode, Recurrent, severe, without psychosis. The MTP dated 11/22/18 had for the problem 1: "Suicidal ideation as evidenced by verbally mentioning suicidal thought without a plan." had STG: "commit to safety for three consecutive days prior to discharge." And the LTG: "will be stabilized in the hospital and return to the community to complete outpatient treatment." For Problem 2: "Aggressive behavior, Adult," the LTG: "(Patient name) will not exhibit aggressive behavior." No STG listed. For the Problem 3: "Anxiety as evidenced by presents with increased fear of situations/being around others;" STG: "patient will effectively use 3 coping mechanisms to help with anxiety attacks." LTG: "will be stabilized in the hospital and return to the community to complete outpatient treatment."

4. Pt A4 was hospitalized on 9/11/18 with a diagnosis of Schizoaffective disorder, Bipolar type, Unspecified Intellectual Disability. The MTP dated 9/13/18 had for the Problem "Suicidal ideations AEB (As Evidenced By) wanting burn her/himself up in a fire" the STG: "Pt. will be free of suicidal ideation for at least 3 days prior to discharge." LTG: "Pt. will return to community without further need for hospitalization. Pt. will follow up with outpatient treatment/therapy after discharge from the hospital." Problem: "Homicidal ideation." STG: "patient will verbalize 3 positive coping skills to use in place of assaultive/aggressive. Patient will verbalize 3 possible stressors or triggers that contribute to assaultive/aggressive behaviors." Problem: "Psychosis." STG: "Patient will take psychotropic medications as prescribed by physician. Patient will attend unit groups and activities. Patient will have decrease in delusions and/or paranoia for 3 consecutive days prior to discharge." LTG: Patient will obtain and maintain maximum level of functioning after discharge without need for further hospitalization."

5. Pt. A5 was hospitalized on 11/23/18 with a Disruptive Mood Disorder. The MTP dated 11/26/18 had for the Problem: Suicidal ideation, STG: "will be free of suicidal ideation at three days prior to discharge." LTG: "will be able to adapt to life stresses with positive coping mechanisms." Problem: "Adolescent with aggressive behavior", STG: [pt. name] will not display aggressive behaviors at least 3 days prior to discharge." LTG: No LTG listed.

6. Pt. A6 was hospitalized on 11/15/18 with a diagnosis of Major Depressive Disorder, Recurrent Severe, without psychotic features. The MTP dated 11/16/18 had for the Problem: "Suicidal ideation", STG: "will be free of SI for 3 days." LTG: "Stabilization in the community without need for recurrent hospitalization."

7. Pt A7 was hospitalized on 9/12/18 and the MTP dated 9/13/18 had for the Problem: "Sexual abuse of adolescent", STG: "Participate in individual and group therapy." LTG: "Continue with outpatient therapy post discharge." Problem: "Attachment disorder", STG: "provide a safe holding environment. Establish therapeutic relationship. Establish and model boundaries." LTG: "Work through termination issues - loss of therapeutic relationship." Problem: "Difficulty controlling anger." STG: "patient will be free of aggressive behaviors while on unit. Pt will learn 3 positive coping skills." LTG: " Patient will utilize learned coping skills to refrain from violent behaviors." Problem: "At risk of danger to others." STG: "Violence: Patient needs to not harm others; follow rules of unit; comply with staff direction." LTG: Patient will verbalize absence of homicidal ideations; display obvious control behavior and compliance with authority."

8. Pt A8 was hospitalized on 11/15/18 and the MTP dated 11/16/18 had for the Problem: "Suicidal ideation." STG: "Pt. will be free of suicidal ideation for at least 3 days prior to discharge.", and the " LTG: "Pt. will return to the community without need for further hospitalization. Pt. will follow up with outpatient treatment/therapy after discharge from the hospital." Problem: "Aggression", STG: "patient will verbalize 3 positive coping skills to use in place of assaultive/aggressive. Patient will verbalize 3 possible stressors or triggers that contribute to assaultive/aggressive behaviors."Patient will not display any assaultive/aggressive behaviors and return to the community without further need of hospitalization. Pt. will follow up with outpatient treatment/therapy after discharge from hospital."

Staff Interview:

In a meeting with the Director of Quality Assurance (DQA), Director of Nursing (DON), Assistant Director of Nursing (RN6), Program Managers 1, 2, and 3 on 11/27/18 at 1:25 p.m. the above deficiencies were reviewed, and they did not dispute the findings.

Based on record review, observation, and staff interview, the facility failed to identify in the Master Treatment Plans (MTPs) individualized and specific active treatment interventions or modalities to address each patient's presenting psychiatric diagnoses or problems for eight (8) out of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, MTPs had the following deficiencies:

I. The intervention statements were non-individualized generic or routine discipline job duties rather than active treatment interventions directed at specific presenting psychiatric symptoms. Intervention statements also failed to state the frequency of contact, the focus of treatment, and whether they would be delivered in group or individual sessions. There were no interventions listed to be provided by activity therapy and no interventions listed to be provided by the psychiatrist for five (5) of eight (8) active sample patients (A1, A4, A5, A6, and A8).

II. The MTPs did not list the groups outlined on unit schedules and attended by patients despite the facility's expectation that all patients attend these scheduled groups.

These deficiencies result in treatment plans that failed to provide guidance to staff regarding the specific interventions and purpose for each. The interventions also failed to reflect a comprehensive, integrated, and individualized approach to interdisciplinary treatment and potentially leads to inconsistent and ineffective treatment with no specific focus of treatment.

Findings include:

I. Lack of individualized active treatment interventions:

A. Record Review

1. Patient A1's MTP, dated 9/13/18, had the following deficient intervention statements for the problem of "Anxiety with Depression."

Psychiatrist Interventions: There were no Attending Psychiatrist interventions for this problem."

Registered Nurse Interventions: There were no RN interventions for this problem."

Social Work Interventions: "Discharge Planning and Follow Up Appointments." "[Patient's name] will participate in individual, group, and family therapy with [Staff's name] and therapy staff to decrease psychiatric symptoms." The intervention statement regarding discharge planning reflected routine social work job duties, not active treatment interventions to address specific discharge issues and barriers. The intervention statement was identical or similarly worded for active sample patients A2, A4, A5, A6, and A8, therefore it was not individualized.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

2. Patient A2's MTP, dated 11/20/18, had the following deficient intervention statements for the problem of "Bipolar disorder, current episode depressed, severe, with psychotic features AEB [sic] reporting depressed mood associated with not eating and not completing ADLs; patient reportedly stated [s/he] killed a snake that disappeared. This was not witnessed by others who were present."

Psychiatrist Interventions: "Prescribe medications and adjust as needed; close watch." These interventions were generic routine psychiatrist job duties, not active treatment interventions showing plans to meet with the patient in to provide information regarding specific prescribed medication at a specified frequency.

Registered Nurse Interventions: "Administer medications as ordered; monitor for medication side effects, efficacy, and compliance; monitor mood, affect, and sleep; Q15 minute monitoring ..." "TCI (Therapeutic Crisis Intervention); assist patient in utilizing positive coping skills; encourage participation in groups and unit activities; limit setting; reorient to reality as needed." The intervention regarding assisting the patient in using coping skills did not include whether it would be implemented in individual or group sessions. Also, there was no frequency of contact or focus of treatment based on the patient's presenting psychiatric symptoms. The other interventions were routine RN job duties, not active treatment intervention to be conducted in individual or group sessions to help the patient to improve his/her presenting symptoms.

Social Work Intervention: "Discharge Planning and Follow Up Appointments." This intervention statement reflected routine social work job duties, not active treatment interventions conducted in individual or group sessions with the patient to address specific discharge issues and barriers at a particular frequency.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

3. Patient A3's MTP, dated 11/22/18, had the following deficient intervention statements for the problem of "Suicidal ideation as evidenced by verbally mentioning suicidal thoughts without a plan."

Psychiatrist Interventions: "Prescribe medications and adjust as needed; suicide precautions." These interventions were non-specific and routine psychiatrist job duties, not active treatment interventions showing meeting with the patient at a specified frequency to provide information regarding prescribed medications.

Registered Nurse Interventions: "Teach positive coping skills." "Monitor [his/her] mood, affect, vital signs and sleep." "Will provide a safe and secure environment." "Encourage attendance and participation in unit activities." The intervention to teach coping skills did not include a method of delivery (group or individual sessions), a frequency of contact, and a focus of treatment. The other interventions were routine RN job duties.

Social Work Interventions: "Individual, Family, and Group Therapy will be provided in order to identify positive stressors/triggers for SI and replace with positive coping skills." The interventions did not include a frequency of contact, and a focus of treatment reflecting possible coping skills this patient might use based on assessed needs. The intervention was identical or similarly worded for active sample patients A4 and A5. Therefore, the intervention was not individualized.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

4. Patient A4's MTP, dated 9/13/18, had the following deficient intervention statements for the problem of "Suicidal ideation AEB (As Evidenced by) wanting to burn [himself/herself] in a fire."

Psychiatrist Interventions: There were no Attending Psychiatrist interventions for this problem."

Registered Nurse Interventions: "Place on suicide precautions. Provide safe and secure environment," "Teach and encourage positive coping skills." "Administer medications as ordered and monitor for efficacy and side effects." "Encourage active participation in group activities ..." The intervention to teach coping skills did not include a method of delivery (group or individual sessions), a frequency of contact, and a focus of treatment. The other interventions were routine RN job duties, not active treatment interventions such as plans to provide medication education in individual or group sessions.

Social Work Interventions: "Discharge planning and follow up appointments ..." "Individual, Family, and Group Therapy will be provided in order to identify positive stressors/triggers for SI and replace with positive coping skills." The interventions did not include a frequency of contact, and a focus of treatment reflecting possible coping skills this patient might use based on assessed needs.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

5. Patient A5's MTP, dated 11/26/18, had the following deficient intervention statements for the problem of "Suicidal ideation as evidenced by verbally to [his/her] adoptive mother that [s/he] wished [s/he] were dead, as well as attempting to jump out of moving vehicle.

Psychiatrist Interventions: There were no Attending Psychiatrist interventions for this problem."

Registered Nurse Interventions: "Provide a safe and secure environment." "Teach positive coping skills." "Encourage attendance and participation in unit activities." "Allow individualized time to talk with staff regarding problems and personal issues." "Monitor Vital Signs, Mood, Affect, and sleep." "Administer medications per order." The intervention to teach coping skills did not include a method of delivery (group or individual sessions), a frequency of contact, and a focus of treatment. The other interventions were routine RN job duties. There was no intervention to show RNs plans to provide medication education.

Social Work Interventions: "Care management and discharge planning to be provided by [Staff's name] and Social Services." This intervention reflected routine social worker job duties. "[Patient's name] will participate in individual, Family, and Group Therapy with [Staff's name] and therapy staff to decrease psychiatric symptoms." The interventions did not include a frequency of contact, and a focus of treatment reflecting possible coping skills this patient might use based on assessed needs.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

6. Patient A6's MTP, dated 11/16/18, had the following deficient intervention statements for the problem of "Suicidal ideation AEB patient reported having SI (suicidal ideation)."

Psychiatrist Interventions: There were no attending psychiatrist interventions for this problem.

Registered Nurse Interventions: "Place patient on suicide precautions." "Maintain suicide precautions." These intervention statements were routine RN job duties, not active treatment interventions to be conducted in individual or group sessions to help the patient to improve his/her presenting symptoms.

Social Work Interventions: "Case management and discharge planning to be provided by [Staff's name] and Social Services." This intervention reflected routine social worker job duties. "[Patient's name] will participate in therapy services to assist with decreasing psychiatric symptoms and increasing healthy coping skills." This intervention stated what the patient would do instead of what the social worker would do to assist the patient in individual and group sessions. Also, the intervention statement did not include a frequency of contact and the focus failed to identify specific psychiatric symptoms and suggested coping skills for this patient based on assessed needs.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

7. Patient A7's MTP, dated 9/13/18, had the following deficient intervention statements:

a. Problem: "Sexual abuse of adolescent."

Psychiatrist Interventions: "Provide support and encouragement. Encourage patient to participate in individual therapy." These interventions were generic and represented routine MD job duties.

Registered Nurse Interventions: There were no registered nurse interventions for this problem. [Note: This contained interventions that were the responsibility of the psychiatrist such as teaching coping skills. The RN assigned these interventions, but they represented interventions that were usually the responsibility of RN staff, not the psychiatrist.]

Social Work Interventions: There were no social worker interventions for this problem.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

b. Problem: "Difficulty controlling anger AE banging head, kicking dayroom window, charging peer and putting [his/her] hands on [him/her]."

Psychiatrist Interventions: "CPI as a last resort for safety of all involved. Encourage patient to attend groups and therapy. Teach coping skills." " ... Order 1:1 monitoring as needed. Prescribe medication as needed." These intervention statements included routine job duties. There was no intervention showing that the psychiatrist would be meeting with the patient in individual sessions to provide information about specific prescribed medications.

Registered Nurse Interventions: There were no registered nurse interventions for this problem.

Social Work Interventions: "Case Management to provide discharge planning and follow up care ..." "Encourage compliance with treatment plan after discharge. Confirm that pt [patient] and family know their Mental Health resources prior to discharge." These interventions reflected routine social worker job duties.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

8. Patient A8's MTP, dated 11/16/18, had the following deficient intervention statements for the problem of "Suicidal ideation."

Psychiatrist Interventions: There were no attending psychiatrist interventions for this problem.

Registered Nurse Interventions: "Monitor mood, affect, and sleep; Q15 minutes monitoring; allow one on one time for verbalizing feelings." "Encourage active participation in group activities as well as individual therapy sessions. Encourage compliance with plan of care ..." "Teach and encourage positive coping skills. TCI as last resort to provide safety to pt. (patient) and peers." The intervention to teach coping skills did not include a method of delivery (group or individual sessions), a frequency of contact, and a focus of treatment. The other interventions were routine RN job duties.

Social Work Interventions: "Individual, Group therapy will be provided." These interventions did not include a frequency of contact and a focus of treatment based on the patient's assessed needs and presenting symptoms. "Case management to provide discharge planning and follow up care ..." "Encourage compliance with treatment plan after discharge. Confirm that pt [patient] and family know their Mental Health resources prior to discharge." These intervention statements were generic and routine social worker job duties.

Activity Therapy Interventions: There were no activity therapy interventions for this problem."

B. Interviews

1. During an interview on 11/27/18 at 11:40 a.m., RN3, did dispute the findings that the MTPs contained RN job duties such as administering medications and monitoring patients' behaviors. She agreed that the interventions related to "teaching coping skills" did not state whether the intervention would be delivered in individual or group sessions, a frequency of contact, or the focus of treatment based on the patients presenting symptoms.

2. In an interview on 11/27/18 at 1:20 p.m., the Director of Nursing (D.O.N.), Director of Quality Improvement, and Program Directors for the Adolescent, Children and Adult Units did not dispute with findings that intervention statements were routine job duties such as prescribing medications, administering medications, and monitoring behaviors instead of individualized and specific active treatment interventions based on each patient's presenting problems. They also did not dispute the findings that intervention statements did not contain the frequency of contact or focus of treatment.

3. In an interview on 11/28/18 at 9:12 a.m., the D.O.N., after reviewing some of the MTPs for active sample patients, acknowledged that many nursing interventions statements were routine job duties. She did not dispute the finding that the intervention statements related to patient teaching did not state whether they would be implemented in individual sessions and did not include a frequency of contact or focus of treatment based on presenting symptoms.

II. Scheduled active treatment measures not included in MTPs:

A. Observations

1. During an observation on 11/26/18 on the Adolescent Unit from 2:30 p.m. to 3:40 p.m., a "Creative Expressive" Group was on the unit schedule to start at 2:30 p.m. in the Craft Room. In a discussion at 2:37 p.m., BHT 1 stated, "We are not holding the group today, the doctor wants to see patients." All 13 patients stayed on the Unit instead of attending the scheduled activity therapy group. In a discussion on 11/26/18 at 2:45 p.m., the Attending Psychiatrist confirmed that he was seeing the patients but stated, "I usually see the patient one at a time where ever they are located." At 2:55 p.m., the adolescents were escorted to the Craft Room in the basement for the group. The patients played a game called "Jenga." Active sample patient A5 and A6 attended along with 13 patients and was facilitated by BHT 1. The MTPs for active sample patients A5 and A6 did not include this activity therapy group.

2. During an observation on 11/27/18 from 9:30 a.m. to 10:00 a.m., a group on the unit schedule titled, "Crafts" scheduled from 9:00 a.m. to 10:00 a.m. and conducted in the Craft Room in the basement. Active sample patients A5 and A6 attended along with seven (7) other adolescents. In a discussion, BHT 1 stated that the patient had just completed an activity that requested them to identify three people they admire on a handout with three trophies and to write on the back of the handout why they admired these people. The MTPs for active sample patients A5 and A6 did not include this activity therapy group.

3. During an observation on 11/27/18 from 10:10 a.m. - 10:45 a.m. a group was held in the craft room by the LATA. Active sample patients A7 and A8 along with nine (9) other patients. The topic was "What do you like about school" and "Comfortable and uncomfortable locations at school." The children used a red, green, and yellow marker to show on a blueprint of a school where they felt "comfortable, uncomfortable, and "so-so." The MTPs for active sample patients A7 and A8 did not include this activity therapy group.

B. Record Review

1. A review of the posted unit daily schedules for Adolescent, Children, and the two Adults Units showed the following activity therapy groups. This review revealed that the MTPs of the active sample patients did not include any of the activity therapy interventions observed by the surveyor or any activity therapy interventions listed below on the unit active treatment schedule.

a. Adolescent - Monday - Friday: "9:00 a.m. - 10:00 a.m. Crafts; 10:00 a.m. - 11:00 a.m. Gym (Gymnasium) Level II & III - Level I on Unit; 2:30 p.m. - 3:30 p.m. Creative Expressions; 7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..." [Note: Nursing staff, Behavioral Health Technicians (BHTs) conducted these groups on the first day of the survey (11/26/18)]. Weekend/Holiday Schedule: - "8:15 a.m. - 9:00 a.m. Crafts 12:00 p.m. - 1:00 p.m. (Level II & III), Gym/Yard (Level II & III): Level I - Day Room; 5:00 p.m. - 6:00 p.m. Craft Room; 6:00 p.m. - 7:00 p.m. Rec Room."

b. Children - Monday - Friday: "10:00 a.m. - 11:00 a.m. Craft Gym; 1:30 p.m. - 2:30 p.m.
Craft; 1:40 p.m. - 2:40 p.m. Outside/Gym; 4:40 p.m. - 5:45 p.m. Creative Arts or Gym ..." Level II & III - Level I on Unit; 2:30 p.m. - 3:30 p.m. Creative Expressions; 7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..." Weekend/Holiday Schedule: 9:00 a.m. - 10:00 a.m. Crafts (Activity Therapy Staff); 1:00 p.m. - 1:50 p.m. Gym (Activity Therapy Staff); 5:10 pm - 6 pm - Gym (CU staff). [Note: During a discussion on 11/28/18 at 11:20 a.m., the Director of Social Work stated that the LATA did not work weekend and BHTs provided the craft and gym activity on weekends and holidays.]

c. Two Adult Units (Similar Schedule) - Monday - Friday: "10:00 a.m. Crafts ...; 1:30 p.m. - 2:30 p.m. Art Therapy; 2:30 p.m. Recreation ...; 4:00 p.m. Hobby Workshop [West Unit]; Creative Expressions [East Unit]." Weekend/Holiday Schedule: "10:15 a.m. Crafts; 2:30 p.m. Recreation; 4:00 p.m. Creative Expression [East Unit]; Hobby Workshop [West Unit]."

C. Interviews

1. In an interview on 11/27/18 at 11:15 a.m., the Lead Activity Therapy Aide stated that he did not attend the treatment planning meeting and had no responsibilities for entering activity therapy interventions on the MTPs.

2. In an interview on 11/27/18 at 2:53 p.m., the Director of Social Work who provided oversight for social services and activity therapy, confirmed that MTPs do not include the activity therapy groups listed on the unit's active treatment schedules.

3. In a meeting with the Medical Director on 11/28/18 at 10 a.m., a sample of the above deficient treatment interventions were reviewed, and he did not dispute these findings.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) contained the name of registered nurse responsible for each nursing intervention identified in Master Treatment Plans of five (5) out of eight (8) active sample patients (A3, A4, A5, A6, and A8). This failure results in the patient and other staff being unaware of which registered nurse was assuming responsibility for the intervention being implemented and documented.

Findings include:

A. Record Review

1. Patient A3 (MTP dated 11/23/18) had no designation of the registered nurse (RN) for each nursing intervention associated with psychiatric problems and treatment goals. The MTP contained the name of the assigning RN but did not include the RN responsible for the intervention. The section titled "Staff Responsible" was left blank.

2. Patient A4 (MTP dated 9/13/18) had no designation name of the RN and social worker (SW) for each intervention associated with psychiatric problems and treatment goals. The MTP contained the name of the assigning RN and SW but did not include the RN responsible for the intervention. There was no section titled "Staff Responsible" on the printed MTP.

3. Patient A5 (MTP dated 11/26/18) had no designation name of the RN for each intervention associated with the psychiatric problems and treatment goals. The MTP contained the name of the assigning RN but did not include the RN responsible for the intervention. There was no section titled "Staff Responsible" on the printed MTP.

4. Patient A6 (MTP dated 11/16/18) had no designation name of the RN for each nursing intervention statement associated with psychiatric problems and treatment goals. The MTP contained the name of the assigning RN but did not include the RN responsible for the intervention. There was no section titled "Staff Responsible" on the printed MTP.

5. Patient A8 (MTP dated 11/16/18) had no designation name of the RN for any of the assigned nursing intervention and one social work intervention associated with psychiatric problems and treatment goals. The MTP contained the name of the assigning RN and SW but did not include the RN and SW responsible for all of the interventions. There was no section titled "Staff Responsible" on the printed MTP.

B. Interview

In an interview on 11/27/18 at 1:20 p.m., the Director of Nursing (D.O.N.), Director of Quality Improvement, and Program Directors for the Adolescent, Children and Adult Units did not dispute with findings that there was no staff responsible for each intervention on the MTPs.

Based on record review and interview, the facility failed to document treatment notes for active interventions assigned to registered nurses and listed on Master Treatment Plans (MTPs) for five (4) of eight (8) active sample patients (A3, A4, A5, and A8). Also, there was a failure to document treatment notes for activity therapy groups listed on unit schedules for eight (8) of eight (8) active sample patient (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, there was no or limited documented evidence to show detailed and comprehensive information that included the patients' attendance or non-attendance in active treatment interventions, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed. This review revealed the following findings regarding assigned treatment interventions to (1) registered nurses (RN) on the MTPs; (2) licensed nursing staff (RNs and Licensed Practical Nurses (LPNs) on unit schedules; and (3) the lead activity therapy aide (LATA) and Behavioral Health Technicians (BHTs) who were nursing staff providing activity therapy listed on the unit schedules.

1. RN Interventions on MTPs

a. Four patients (date of MTPs in parenthesis) A3 (11/22/18), A4 (9/13/18), A5 (11/26/18), and A8 (11/16/18) had the following identically or similarly worded RN interventions: "Teach positive coping skills" or "Teach and encourage positive coping skills." There was no frequency of contact or focus of treatment based on each of these patient's presenting psychiatric symptoms.

b. A review of RN shift notes and the "Patient Education Record" from 11/20/18 through 11/26/18 revealed no documentation that an RN met with these patients in individual or group sessions to discuss coping skills. Specifically, there was no documentation about the number and duration of contacts with patients or any information regarding the coping skills discussed. Also, there was no evidence showing how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

2. Licensed Nursing Staff Interventions on Unit Schedules

a. The unit schedules contained an active treatment measure titled "Patient Education" scheduled from 3:30 p.m. to 4:00 p.m. Monday - Friday and weekends from 10:15 a.m. to 11:00 a.m. on for the Children's Unit. During a discussion on 11/26/18 at 11:25 a.m., when asked about this scheduled activity, RN 5 stated this was not a group but was "one-to-one" medication education of patients by the LPN. The D.O.N. confirmed on 11/28/18 at approximately 9:12 a.m. that LPNs and sometimes the RN implemented the "Patient Education" list on the unit schedule.

b. A review of the "Patient Education Record" from 11/20/18 through 11/26/18 revealed there was one (1) note out of seven (7) possible notes documented for active sample patient A7. There was no documentation about the number and duration of contacts with the patient. Although the medications were listed, there was limited information about how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

3. Activity Therapy Interventions listed on unit schedules

a. A review of the electronic medical record on 11/27/18 at 12:10 p.m. revealed that none of the following groups listed on units' schedules were documented in the electronic medical record by BHT. A review of the "Patient Education Records" documented by BHTs, showed no clear relationship to the activity group listed on the unit schedules. In addition, there was no documentation about how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions. The electronic medical record contained no documentation of the "Art therapy" listed on the Adult unit schedules for active sample patients A5, A6, A7, and A8.

Adolescent Unit - Monday - Friday: "9:00 a.m. - 10:00 a.m. Crafts; 10:00 a.m. - 11:00 a.m. Gym (Gymnasium) Level II & III - Level I on Unit; 2:30 p.m. - 3:30 p.m. Creative Expressions; 7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..." Nursing staff, Behavioral Health Technicians (BHTs) conducted these groups on the first day of the survey (11/26/18).

Children Unit - Monday - Friday: "10:00 a.m. - 11:00 a.m. Craft Gym; 1:30 p.m. - 2:30 p.m.
Craft; 1:40 p.m. - 2:40 p.m. Outside/Gym; 4:00 p.m. - 5:00 p.m. Creative Arts or Gym." Level II & III - Level I on Unit; 2:30 p.m. - 3:30 p.m. Creative Expressions; 7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..."

c. Two Adult Units (Same Schedule) - Monday - Friday: "10:00 a.m. Crafts ...; 1:30 p.m. - 2:30 p.m. Art Therapy; 2:30 p.m. Recreation ...; 4:00 p.m. Hobby Workshop." Gym (Gymnasium) Level II & III - Level I on Unit; 2:30 p.m. - 3:30 p.m. Creative Expressions; 7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..."

B. Interview

1. In an interview on 11/27/18 at 11:15 a.m., the Lead Activity Therapy Aide stated, I don't document any of the activity therapy groups." When asked if he would document the activity therapy that he conducted at 10:10 a.m., stated, "I think the BHTs document the groups."

2. In an interview on 11/27/18 at 2:53 p.m., the Director of Social Work who provided oversight for social services and activity therapy, confirmed that the activity therapy groups were not documented in the clinical record to show topics discussed and how the patients respond to activity therapy groups.

Based on record review, interview and observation, the facility failed to provide active treatment including alternative interventions for two (2) of eight (8) active sample patients (A1and A2). The patients were unwilling to attend many of their assigned therapeutic activities/groups. Failure to provide active treatment results in affected patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially hindering their improvement and prolonging their discharge.

Findings include:

1. Patient A1 was admitted on 9/11/18. The Psychiatric Evaluation dated 9/11/18 listed the diagnoses as "Schizophrenia, Noncompliance." The documented reason for hospitalization was "I don't want to live with my fourth cousin." The patient was described as "has significant delusions", "has very significant psychosis but has zero insight." "Currently court committed."

The Master Treatment Plan (MTP) dated 9/13/18 listed for the Problem, "Anxiety with depression." the "STG/LTG: "The case manager will provide discharge planning upon admission. Patient will at least know some coping skills to manage his/her depression and anxiety and be medication compliant." The interventions included "Discharge planning and follow up appointments [staff name] Case Management Staff." and "[Pt. name] will participate in individual, group, family therapy with [staff name] and therapy staff to decrease psychiatric symptoms." No Physician, Nursing and Activity/Recreation Therapy [AT/RT] interventions listed.

The goals and interventions on the MTP were not amended to address the patient's non-participation in groups and non-interaction with staff/peers, nor was there evidence that alternative treatment interventions were available for Patient A1.

Review of the Therapeutic Observation Record (15-minute checks) from 11/25/18-11/27/28 revealed, all of the entries placed the patient in his/her room, hallway or shower. The Patient Education Record (Group notes) from 11/24/18 to 11/27/18 revealed that Patient A1 had failed to attend any of his/her assigned groups.

Review of Nursing Progress Notes revealed the following:

11/25/18, 12:41PM - "patient is noted to be in bed for most of day". 11/25/18, 10:39 PM- "continues to isolate self and sleep most of day", 11/26/18, 02:03 PM- "Not Attends/Participates in Grp/Activity [sic]"

MD Progress Notes:

11/25/18-"sleeping constantly, taking [his/her] meds but participates little in therapy or sexual activity [sic]." 11/26/18- "sleeping constantly, taking meds but participates little in therapy or sexual activity [sic]."
Weekly Treatment Plan Review Notes from 9/20/18 to 11/22/18 reveals: (dates in parenthesis)
"primarily keeps to self and withdrawn"(9/20/18), "primarily isolates him/herself,--- does not engage with others" (9/27/18), "primarily isolates him/herself and sleeps" (10/4/18), "is compliant with medications but otherwise does not participates at all" "locked out of his/her room from 09:00am to 02:00pm to encourage his/her participation." (10/11/18), "has not engaged in the therapeutic milieu" (10/18/18), "remains locked out, but will sleep in the floor and refuse to participate." (10/25/18), "does not participate, he/she primarily spends his/her time sleeping, he/she requires prompting to shower" (11/1/18), "continues to have minimal participation" 11/15/18, "He/she does not participate in the therapeutic milieu" (11/22/18).

Observation on the Adult East Unit on 11/26/18 at 3:00pm revealed that Patient A1 was in bed during his/her assigned Recreation Group. Observation on 11/27/18 at 10:30am revealed that Patient A1 was sitting in his/her room alone during his/her assigned Crafts Group. When asked about therapeutic activities/group participation, patient stated "don't go to groups, just don't want to be bothered."

During interview on 11/26/18 at 2:10pm, RN2 when asked why Patient A1 was not in group, stated that "try to engage with activities, but he/she refuses".

2. Patient A2 was admitted on 11/17/18. The Psychiatric Evaluation dated 11/17/18 listed the diagnoses as "Bipolar Disorder, Type 1, severe, MRE (Most Recent Episode) depressed." The documented reason for hospitalization was "Worsening depression and psychosis". The patient was described as "not eating or bathing at home", "endorses hopelessness."

The Master Treatment Plan (MTP) dated 11/20/18 listed for the Problem, "Bipolar disorder, current episode depressed, severe with psychotic features...." the STG: "will maintain adequate nutrition, sleep and activity; as well as reality-based thinking for three consecutive days prior to discharge." LTG: "will be stabilized in the hospital and return to the community to complete outpatient treatment." The interventions included for the MD: "Prescribe medications and adjust as needed; close watch." Nursing:"Administer medications as ordered; monitor for medication side effects, efficacy, and compliance; monitor mood, affect, and sleep; Q15 minute monitoring; allow one on one time for verbalization of feelings." TCI (Therapeutic Crisis Intervention); assist patient in utilizing positive coping skills; encourage participation in groups and unit activities; limit setting; reorient to reality as needed." Encourage patient to complete ADLs on own." Case management staff: "Discharge planning and Follow up Appointments", Therapist: "(Pt. name) will participate in individual, group, and family therapy with (staff name) to decrease psychiatric symptoms." No Activity/Recreation Therapy [AT/RT] interventions listed.

The goals and interventions on the MTP were not amended to address the patient's non-participation in groups and non-interaction with staff/peers, nor was there evidence that alternative treatment interventions were available for Patient A2.

Review of the Therapeutic Observation Record (15-minute checks) from 11/25/18-11/27/28 revealed, all of the entries placed the patient in his/her room, hallway or TV room. The Patient Education Record (Group notes) from 11/20/18 to 11/27/18 revealed that Patient A2 had failed to attend all but one (1) group.

Review of Nursing Progress Notes revealed the following:

11/25/18, 11:05AM - "noted to sleep most and refuses activities interaction with peers", 11/25/18, 09:31 PM- "Not attends/Participates in Grp/Activity (sic)", 11/26/18, 02:45 PM- "Patient did not go to group therapy today. Isolating to bed a lot."

MD Progress Notes:

11/25/18-"Still very depressed and has very low motivation." 11/26/18- "Patient's mood is extremely depressed and he/she appears to have a history of bipolar disorder."

Observation on the Adult East Unit on 11/26/18 at 3:10pm revealed that Patient A2 was in bed during his/her assigned Recreation Group. Observation on 11/27/18 at 10:30am revealed that Patient A2 was sitting in his/her room alone during his/her assigned Crafts Group. When asked about therapeutic activities/group participation, patient stated "I just don't feel like it."

During interview on 11/26/18 at 2:40pm, SW2 when asked about patient's lack of attendance at groups she stated that "he/she went to 1 group since admission, i meet with him twice a week 1 to 1."

Staff Interview:

In a meeting with the Director of Quality Assurance (DQA), Director of Nursing (DON), Assistant Director of Nursing (RN6), Program Managers 1,2, and 3 on 11/27/18 at 1:25 p.m. and the Medical Director on 11/28/18 at 10:00 a.m. the above deficiencies were reviewed, and they did not dispute the findings. The Medical director further stated "Agree, it looks bad".

Based on record review and staff interview the Medical Director failed to provide adequate oversight to ensure that:
I. The Physical Examinations included screening neurological examinations for three (3) of eight (8) active sample patients. (Refer to B109)

II. The Master Treatment Plans (MTPs) included patient specific problem statements (refer to B119), Short Term Goals and Long-term Goals (STGs and LTGs) were written in observable, behavioral and measurable terms (refer to B120), included a substantiated diagnosis (refer to B121)

III. The MTPs included individualized, active treatment interventions including frequency, modality and focus of the interventions and involved/responsible staff by name. (Refer to B122 and B123)

IV. All patients receive active including alternative treatments reflecting current needs of the patients and that the MTPs are modified as needed. (B125)

Based on observation, record review, and interview, the Director of Nursing (D.O.N.) failed to provide adequate oversight to ensure quality nursing services. Specifically, the facility failed to:

I. Ensure the development of comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components on the MTPs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6¸ A7, and A8). Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated nursing care, potentially resulting the lack of treatment for patient psychiatric needs and problems. Specifically, the facility did not develop and document Master Treatment Plans (MTP) that:

A. Included individualized patient-related short-term goals which stated what the patient would do to lessen the severity of problems identified on admission for eight (8) of eight (8) active sample patients. (Refer to B121).

B. Included individualized nursing interventions that stated specific active treatment measures with the method of delivery (individual or group sessions), a frequency of contact, and a specific focus or purpose of treatment based on each patient's presenting psychiatric symptoms. Instead, the MTPs included routine RN job duties or were vague, generic and global statements written as active treatment interventions. (Refer to B122).

C. Ensured that Master Treatment Plans (MTPs) contained the name of registered nurse responsible for each nursing intervention identified in Master Treatment Plans of five (5) out of eight (8) active sample patients (A3, A4, A5, A6, and A8). This failure results in the patient and other staff being unaware of which registered nurse was assuming responsibility for the intervention being implemented and documented.

II. Documented comprehensive treatment notes for active treatment interventions assigned to the registered nurses and listed on Master Treatment Plans for four (4) of eight (8) active sample patients (A3, A4, A5, and A8). Specifically, there was no documented evidence to show detailed information that included the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team from determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124)

Based on record review and staff interview:

Record review:

1. The Director of Social Work failed to assure the quality and appropriateness of services provided by the social work staff. Specifically, the Director failed to assure that the Psychosocial Assessments included the anticipated social work roles in treatment for eight (8) of eight (8) (A2, A3, A4, A5, A6, A7 and A8) active sample patients. This failure results in a lack of professional social work information in treatment planning. [Refer to B108]

2. The Director of Social Services failed to provide appropriate and adequate oversight/supervision for seven (7) of eight (8) active sample patients' Psychosocial Assessments performed by non- MSW qualified staff. (A1, A2, A3, A4, A5, A7, and A8) This failure results in lack of professional social services information in patients' treatment and discharge planning.

Staff interview:

In a meeting with the Director of Social Services on 11/27/18 at 2:00 p.m., above deficiencies were reviewed and he agreed with the above findings.

Based on observation, document review, and interview, the facility failed to ensure that there was a coordinated program plan for therapeutic activities with a focus of maintaining the highest level of functioning for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Also, Master Treatment Plans (MTPs) did not contained planned and defined activity therapy group interventions. There was no written document to show a clear purpose of activity therapy program in meeting active treatment goals and rehabilitative needs of each specific patient population served. These deficient practices potentially hinder the restoration or maintenance of patients' level of functioning.

A. Document Review

The facility failed to produce a written comprehensive program description to show rationale and purpose of the therapeutic and rehabilitative activities used to develop and maintain adaptive skills as well as leisure and life skills for the patient population they serve. The only information in writing was one paragraph titled "Activity Therapy" in the facility's " .... Hospital Scope of Services" and a list of "Creative Activity Assignments: Adults, Adolescents, Tween, and Children." This document included a broad overall goal for the 49 activities listed such as "To promote self-expression, creativity, self-awareness, and independence." It was not clear how many of the activities listed were appropriate for each of the patient populations served. Another list titled, "Therapeutic Activities Adult" contained 40 activities for adults with broad goal statements such as, "To promote strategy, concentration, and build confidence."

B. Interview

In an interview on 11/27/18 at 2:53 p.m., the Director of Social Work who provided oversight for social services and activity therapy, confirmed that there that there was no written comprehensive program description for the activity therapy based on the needs and psychiatric problems of the patient populations they serve.

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

I. Employ qualified activity therapy staff to provide and document active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the facility did not have qualified and competent activity therapy staff to complete therapeutic activities assessments to ensure appropriate input into the formulation of the Master Treatment Plans (MTPs), and to offer activity therapy group and individual sessions. Also, there was limited activity therapy programming available for patients after 4:00 p.m. during the week and on the weekend. Activities offered after 4:00 p.m. and on weekends were mostly diversional and were provided by nursing staff. This failure results in patients not receiving a full complement of therapies, patients not being assessed adequately regarding needs and capabilities, and patients not receiving individualized and goal-directed activity therapies.

II. Provide documented evidence showing nursing staff competency to provide activity therapy groups. Specifically, Behavioral Health Technicians (BHTs) provided most of the activity therapy groups listed on unit schedules, especially on the Adult Units. BHTs did not have documented evidence except for an orientation sheet with no documented proof of competency evaluation showing assessment via test or return demonstration. This failure results in unqualified nursing staff assigned to provide activity therapy groups, hampering patients' progress in obtaining their optimal level of functioning.

Findings include:

I. Lack of activity therapy assessments and planned active treatment interventions

A. Document Review

1. The Director of Social Work who provided oversight for activity therapy submitted a list on 11/27/18 at approximately 3:30 p.m. showing the names of BHTs that assist with activities and gym from each unit. These BHTs were assigned to conduct groups listed on the unit scheduled identified by the facility as activity therapy groups. He also confirmed that there were one Lead Activity Therapy Aide and no other qualified activity therapy staff currently available.

2. None of the active sample patients had an assessment. Although an assessment of leisure activities was completed by social work staff in their social work assessment, there was no documented evidence to show how this information was used to formulate activity therapy interventions and determine appropriate active treatment provided by activity therapy staff.

3. None of the eight (8) active sample patients (dates of MTPs in parenthesis) included specific activity interventions on the Master Treatment plan: A1 (9/13/18), A2 (11/20/18), A3 (11/22/18), A4 (9/13/18), A5 (11/26/18), A6 (11/16/18), A7 (9/13/18), and A8 (11/16/18). (Refer to B122)

4. The active sample patients' electronic medical record contained limited or no documentation regarding assigned and implemented activity therapy groups. Specifically, there was no documented evidence to show that activity therapy groups on the unit schedules were held or not held, topics discussed, and the patient's response to interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Refer to B124.

5. A review of the unit schedules showed limited activity therapy scheduled on the evening shifts and weekends. The schedules for the four units revealed the following findings:

a. The Adolescent Unit had two groups scheduled on the evening shift Monday - Friday: "7:00 p.m. - 8:00 p.m. Gym/Yard/Rec (Recreation) Room ..." and 4 scheduled weekends activity therapy groups [Two on the evening shift] - "8:15 a.m. - 9:00 a.m. Crafts 12:00 p.m. - 1:00 p.m. (Level II & III), Gym/Yard (Level II & III): Level I - Day Room; 5:00 p.m. - 6:00 p.m. Craft Room; 6:00 p.m. - 7:00 p.m. Rec Room."

b. The Children Unit had one (1) group scheduled on the evening shift Monday - Friday:
4:40 p.m. - 5:45 p.m. Creative Arts or Gym" and four (4) groups scheduled weekends [one after 4:00 p.m.] - "9:00 a.m. - 10:00 a.m. Crafts (Activity Therapy Staff); 1:00 p.m. - 1:50 p.m. Gym (Activity Therapy Staff); 5:10 pm - 6 pm - Gym (CU staff)."

c. The two Adult Units had one activity therapy group scheduled Monday - Friday on the evening shift: "4:00 p.m. Hobby Workshop. [East Unit]; Creative Expressions [West Unit]." The weekend/holiday schedule included two (2) activity therapy groups - 10:15 a.m. "Crafts; 2:30 p.m. Recreation."

B. Interviews

1. In an interview on 11/27/18 at 11:15 a.m., the Lead Activity Therapy Aide reported, "We had activity therapy but there had been a reduction in force and the Activity Therapy Department was eliminated." He stated that he did not complete an assessment, did not attend treatment planning meeting, had no responsibilities for entering activity therapy interventions on the MTPs, and did not document the activity therapy groups he provided. The LATA also reported that he did not provide activity therapy on the adult units.

2. In an interview on 11/27/18 at 2:53 p.m., the Director of Social Work who provided oversight for social services and activity therapy, stated, "Two years ago we had a program [activity therapy]. He reported that after the reduction in force, "We kept two people at that time. We had art therapy and recreational therapy." He also stated that the art therapist was now providing social services. He also confirmed that there that there was no activity therapy assessment completed by activity therapy staff. He agreed that there was limited activity therapy programming on evenings and weekends.

II. Lack of competency assessment of assigned staff to provide activity therapy

A. Observations

1. During an observation on 11/26/18 on the Adolescent Unit from 2:30 p.m. to 3:40 p.m., a "Creative Expressive" Group was on the schedule to start at 2:30 p.m. in the Craft Room. This group was not held until 2:55 p.m. (Refer to B122). The activity was a game called "Jenga." Active sample patient A5 and A6 attended along with 11 patients and was facilitated by BHT 1. There was no discussion or processing of this activity to address significant learnings and associated treatment goals for the activity with the adolescents. When asked if they discussed or process this activity with the adolescents, BHT 1 stated, "We just make sure they complete it and the [Lead Activity Therapy Aide] will look at them. They get four (4) points for each activity." BHT 3 participated in the game the other two BHTs had little or no interaction or engagement with the adolescents.

2. During an observation on 11/27/18 from 9:30 a.m. to 10:00 a.m., a group on the unit schedule titled, "Crafts" scheduled from 9:00 a.m. to 10:00 a.m. and held in the Craft Room in the basement. Active sample patients A5 and A6 attended along with seven (7) other adolescents. The adolescent completed an exercise from 9:00 a.m. to 9:30 a.m. regarding identifying three persons they admire and why. Later, the adolescents colored preprinted sheet or wrote on the blackboard. BHT 1 was sitting at the table with adolescents, the other BHT staff (BHT 2, 3, and 4) were sitting together and had little or no engagement with the adolescents. The activity ended at 9:50 a.m., and there was no discussion or processing of the activities with the patients.

B. Document Review

1. Competency folders were reviewed with the Staff Development Coordination on 11/27/18 at 2:00 p.m. The competency folders BHT 1 and BHT 3 revealed that there were no competency evaluations such as assessment tests and evaluated return demonstration to ensure these BHTs had the skills and competencies to lead activity therapy groups. Also, there was no training material or any competency information regarding group dynamics, and how to perform and process group activities.

2. A review of the personnel file showed the promotion of the Lead Activity Therapy Aide (LATA) on June 24, 2018. His job description included the following responsibilities: "Conducts comprehensive recreational therapy services designed to facilitate the psychosocial rehabilitation of psychiatric patients ..." and "Charts in patient records as appropriate and/or assigned." The LATA competency folder did not contain any competency evaluations with assessment tests, examination results, or return demonstration evaluations regarding how to conduct and process groups.

C. Interview

1. In an interview on 11/27/18 at 11:15 a.m., the Lead Activity Therapy Aide reported, "We use to have activity therapy, that he held training sessions for BHTs in August but did document this training.

2. In an interview on 11/27/18 at 2:53 p.m., the Director of Social Work admitted that there was no documented evidence that nursing staff (BHTS) conducting the identified activity therapy groups were competent and adequately trained. He stated, "That was a mistake. I am not going to make excuses."

3. During an interview on 11/28/18 at 11:02 a.m., BHT 1 stated that she had received training three months ago that "wasn't very long. She reported this training included information about the activity cabinet, activity supplies, and equipment.