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Based on observation and staff interview, the facility did not maintain the condition of the physical plant in such a manner that the well-being of the patients are assured.

Findings include:

During the tour of the facility on 6/27/2017 at approximately 10:50 AM, the following findings were identified:
(a) Three (3) approximately 8 x 4 inches ceiling tiles, were observed to be stained due to water leak in the 2 North Storage Room.
(b) The cove base, approximately three feet long and four inches high, was observed detached from the wall in the 2 South Multipurpose Room. The Multipurpose Room is used for different patient activities, and this detachment can be a tripping hazard to patients.

The above findings were identified in the presence of Staff A, Deputy Director of Administration and Staff B, Life safety Manger and was brought to the attention of the facility's leaders during the exit conference.

Based on record review and staff interview, it was determined that the Psychosocial Assessments for 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B6, B7, and B9) failed to include a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being made available to the other members of the multidisciplinary treatment team about what efforts the social service staff may pursue.

Findings include:

A. Record Review

The Psychosocial Assessments for the following ten (10) patients (dates of Psychosocial Assessments in parenthesis) all failed to include the anticipated role of the social service staff in discharge planning. Patients A1 (7/29/16), A2 (1/12/17), A3 (4/5/217), A4 (6/2/17), A5 (10/29/17), B1 (3/8/17), B2 (4/4/17), B6 (5/16/17), B7 (4/19/17), and B9 (5/31/17).

B. Staff Interview:

On 6/27/17 at 11:05 a.m., the Director of Social Work was interviewed. A partial focus of the interview was the findings described in Section A above. After examining the Psychosocial Assessments for patients A1, A2, A3, and A5, the Director agreed that the anticipated role of the social service staff in discharge planning was not described.

Based on record review and interview, the facility failed to consistently formulate treatment goals that were relevant to the patients' psychiatric condition for six (6) of 10 active sample patients (A2, A5, B1, B2, B6, and B9). The goals were either not measurable or were staff goals (what staff wanted the patient to achieve) rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge the effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress.
Findings include:

A. Record Review

1. In patient A2's Master Treatment Plan (MTP), dated 3/23/17, for the problem, "chronic mental illness, substance abuse," the staff goal was, "[Name of patient] will continue to develop a relapse prevention plan that identifies the stages of relapse and will verbalize 2 - 3 specific prevention techniques for each stage of relapse in both 1:1 (one to one) sessions and group interventions over the next quarter."

2. In patient A5's MTP, dated 7/14/17, for the problem of, "patient has history of suicidal ideations and attempts [s/he] has paranoid delusional thoughts of being raped, and being loud and threatening," the staff goal was, "Patient will report in sessions that [s/he] is experiencing thoughts or feelings of being raped less and agreed to talk to staff about the problem instead of threatening others."

3. In patient B1's MTP, dated 4/10/17, for the problem (stated in MTP, dated 3/9/17) of "chronic mental illness; persistent severe psychotic illness from the age of 14, depressed mood, including history of anxiety, depression, non-adherence with treatment, history of scratching wrist, but no serious suicidal attempt," A staff goal was, "In individual and group sessions, [Name of patient] will be able to verbalize at least 1 trigger to have zero incidents of self-injurious behavior (super facial cutting and scratching) [him/herself] in individual sessions 2x / week 15 minutes each for the next two months." "[Name of patient] will discuss options for future beyond feelings of helplessness and hopelessness. [S/he] will share with therapist [his/her] plans for the future beyond wanting to live in hospital indefinitely to feel safe." A non-measurable goal was, "During weekly individual and group sessions, [name of patient] will be able to verbalize two benefits of medication adherence to have zero refusal or checking medication for the next two months."

4. In patient B2's MTP, dated 4/2/17, for the problem, "[Name of patient] has a long history of behavior problems, aggressive behavior beginning during early childhood and also during incarcerations and psychiatric hospitalizations. [S/he] exhibits deficits with respect to anger management, impulse control, and frustration tolerance. [His/her] thought process is also paranoid and at times delusional and [s/he] was expressing passive suicidal ideation about 'wanting to disappear' upon admission but denied any suicidal plan or intent." The staff goals were, "[Name of patient] will remain treatment compliant. [S/he] will also remain free from verbally threatening or physically aggressive behavior. [S/he] will discuss [his/her] feelings in sessions and assaultive impulses to any member of the treatment team. [S/he] will attend individual and group sessions, utilize anger management techniques, and employ positive coping skills to help [him/her] stress. "Consumer will have no refusals of prescribed medications as evidenced by nursing, psychiatrist, and medical specialist reports and their progress notes within the next 60 days." "Consumer will be well versed on [his/her] diagnosis or schizophrenia as evidenced by nursing and psychiatrist progress notes within the next 50 days."

5. In patient B9's MTP, dated 6/13/17, for the problem, "[Name of patient] has a pattern of non-adherence with medication, when in the community. This results in increased responsiveness to paranoid delusions and command hallucinations. Despite having some insight into [his/her] illness, [s/he] displays poor judgment regarding treatment. [S/he] stated [s/he] stopped taking [his/her] medications prior to admission because the medications gave [him/her] 'suicidal thoughts'." The non-measurable goal was, "For the next 30 days [Name of patient] will be able to identify 3 'warning signs' for suicidal behavior." The staff did not include how they could tell by verbal or actions of patient when [s/he] was free of suicidal thoughts.

B. Interview

1. In an interview on 6/27/17 around 9:22 a.m. with psychologist 1, the staff goals for patient B2 were discussed. She agreed with the findings.

2. In an interview on 6/27/17 at 11:51 a.m. with the Director of Nursing, the staff and non-measurable goals on many of the active sample patients' MTPs were discussed. She did not dispute the findings.

Based on record review and interview, the medical director failed to monitor that Master Treatment Plans consistently formulated treatment goals that were relevant to the patients' psychiatric condition for six (6) of 10 active sample patients (A2, A5, B1, B2, B6, and B9). The goals were either not measurable or were staff goals (what staff wanted the patient to achieve) rather than an outline of a mental status or functional status level to be obtained. Without a set of defined goals against which to measure progress, it is impossible to judge the effectiveness of treatment and to implement possible changes in treatment in the case of lack of progress. (Refer to B121)

Based on record review and staff interview, it was determined that the Director of Social Work failed to monitor to ensure that Psychosocial Assessments for 10 of 10 patients (Patients A1, A2, A3, A4, A5, B1, B2, B6, B7, and B9) included a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being made available to the other members of the multidisciplinary treatment team about what efforts the social service staff may pursue. (Refer to B108)