HospitalInspections.org

Based on interviews and document review, the hospital failed to ensure that contracted services were evaluated for safety and effectiveness.

Findings:
On the morning of 01/17/17, a list of contracted services was reviewed. No documentation was provided that showed contracted services had been evaluated by the governing body, who is responsible for oversight.

On 01/20/17, the Director of Nursing confirmed contracted services were not evaluated by established quality criteria.

On 01/19/17, the hospital policy titled, "Evaluation of Contracts 08/12", documented "All contracts with physician, vendors, and/or other companies shall be evaluated on annual basis..."

Based on document review and staff interview the hospital failed to adhere to its policy and procedure established for grievances.

Findings:

On 01/18/17 at 2:21 PM, surveyors requested (second request) grievances within the past 12 months. Surveyors were provided grievances for the months of November 2016 and December 2016; the hospital did not provide requested records for the past 12 months.

On 01/18/17 at 2:40 PM, a staff interview was conducted. Staff DD reported the grievances for the past 12 months were unable to be accessed.

On 01/20/17 at 8:38 AM, a policy titled, " Rights and Responsibilities Grievance Policy " revised on 05/24/16 was reviewed. The policy stated, " ...a copy of each formal grievance shall be provided immediately to the Chair of the Grievance Committee and the CEO ...a separate grievance file shall be kept by the grievance coordinator with all materials relating to that investigation ... "


On 1/20/17 at 9:54 AM, an interview with the hospital ' s Director of Nursing (DON) confirmed the hospital does not have any investigative reports for grievances prior to December 2016.

Based on document review and staff interview the hospital failed to:

a. maintain its grievance process as approved by the governing body.

b. ensure grievances are reviewed and resolved by governing body or delegated grievance committee.

Findings:

On 1/19/17 at 10:15 AM, document review of QAPI meeting minutes showed only one meeting titled, " Performance Improvement Committee " dated September 14, 2016 for grievances with hospital ' s response for the past year. Document stated, " ... [Staff B] reported there were five grievances reported and all were resolved ... " No documentation was provided to surveyors for grievance review or resolution by the governing body or delegated committee.

On 1/20/17 at 08:20 AM, a record review of documents titled, " Grievance and Resolution Report " for November 2016 reported five grievances and December 2016 reported one grievance; document also included a grievance without a date/time. Seven grievances not reviewed and resolved by governing body or delegated grievance committee within this timeframe.

On 01/20/17 at 8:38 AM, a policy titled, " Rights and Responsibilities Grievance Policy " revised on 05/24/16 was reviewed. The policy stated, " ...A Grievance Committee shall be assigned with the responsibility to review all grievances so as to be satisfied that a thorough investigation has occurred, and appropriate outcome has been determined ... "


On 1/20/17 at 9:29 AM, Staff DD was interviewed and reported the Grievance Committee only meets when a grievance has been filed.


On 1/20/17 at 9:54 AM, an interview with the hospital ' s Director of Nursing (DON) confirmed the hospital does not have any investigative reports for grievances prior to December 2016, though grievances had been filed.

Based on document review and staff interview the hospital failed to provide documentation of written notice to each patient reporting the grievance resolution, steps taken in the investigation, results, and completion date for seven of seven records (Patient #20, 21, 22, 23, 24, and 25) reviewed.

Findings:

On 1/20/17 at 08:20 AM, a record review of a document titled, " Grievance and Resolution Report " for November and December 2016 reported six grievances and one without a date/time. The grievances did not contain a letter or verification that a letter had been created to report results of the internal investigation for seven of seven records reviewed. (Patient #20, 21, 22, 23, 24, and 25)

On 1/20/17 at 9:29 AM, surveyor requested documentation of written responses to patient's grievances; none were provided.

On 1/20/17 at 9:29 AM, an interview was conducted with Staff DD reported uncertainty of written notice provided to each patient regarding their grievance prior to December 2016.

On 1/20/17 at 9:56 AM, an interview was conducted with Staff EE who reported no documentation of investigations or letters sent to patients were retained. The Director of Nursing confirmed this information.

Based on medical record review, policy review and staff interview the hospital failed to provide a physician's order for restraint/seclusion for one of five patient medical records (Patient #20) reviewed.


Findings:


On 1/20/17 at 2:15 PM, surveyors reviewed medical records. Patient #20 medical record contained a face-to-face nursing assessment for an initial restraint/seclusion without a physician ' s order.


On 1/20/17 at 2:34 PM, a policy titled, " Physician's Orders " revised on 05/12/16 was reviewed. The policy stated, " ...only physicians shall order seclusion or restraint ... "


On 1/20/17 at 2:49 PM, Staff B verified Patient #20 electronic and paper chart did not contain a physician order and reported unsure why the order is not present.

Based on medical record review and policy review the hospital failed to complete a face-to-face assessment after a restraint or seclusion was initiated for one of five patient medical records (Patient #13) reviewed.

Findings:

On 1/20/17 at 2:15 PM, surveyors reviewed medical records. Patient #13 medical record did not contain a face-to face assessment.

On 1/20/17 at 2:34 PM, a policy titled, " Care and Treatment Behavior Management Staff Responsibilities in Seclusion/Restraint " revised on 05/18/16 was reviewed. The policy stated, " ...a face-to face assessment with the patient within one (1) hour of the placement of the patient into seclusion or restraint ... "

Based on observations, interviews, and document review, the hospital failed to ensure:
a. adequate number of licensed nurses were immediately available to meet the needs of patient care, and
b. qualified staff were assigned patient care responsibilities.

Findings:

a. On 01/19/17 at 12:30 p.m., a bed count was performed for the adult and adolescent units; each unit had 16 beds. The hospital provided census information that averaged as follows: adult unit 57 patients/ month and the adolescent unit of 59 patients / month.

During the course of the survey, multiple interviews were conducted with the register nurses and mental health technicians.
~Staff Q and I stated they spent 80-90% of their assigned day within the confines of the nursing station. The nursing station provided limited view of the unit and would limit the nurse's ability to provide supervision of mental health technicians (MHT) during patient care activities. (see Tag A-095)
~Staff Q and I stated their job responsibilities included, but were not limited to: labeling specimens, answering the phone (from other units, lab, physicians, family etc), processing admissions and discharges, administering medications and documentation, performing medication reconciliations, completing discharge summaries, orienting new staff, performing daily assessments, performing finger stick blood sugars, obtaining the admission packet consents, documenting untoward events (medical and restraint seclusion, face to face assessments), performing nutritional assessments, and coordinating transfers.

On 01/19/17, Staff Q stated the job was paper oriented, and did not feel there was enough time to complete the assigned tasks. Staff Q stated it was often necessary to stay an hour and a half over the shift to complete the required paperwork.

On 01/17/17 at 11:43 a.m., Staff I stated having feelings of being overwhelmed.

On 01/19/17 at 1:52 p.m., Staff I stated no lunch or breaks had been provided during the day shift for this date.

The activity schedule allocated 30 minutes for the medication pass; however, Staff Q stated morning medication pass took 2 hours to complete.

The mental health technician stated responsibilities included, but were not limited to: conducting 15 minute checks, assisting answering the phones, conducting group teaching sessions, providing escort to activities and smoke breaks, processing belongings, providing admission body searches, monitoring patient vital signs, collecting satisfaction surveys, applying therapeutic holds and restraints, and serving patient meals.

On 01/19/17, during an interview, Staff J stated the patients had increased in acuity in the past years. Staff J stated psychotic patients were sometimes difficult to manage. Staff J stated there was not "real back up, but we just deal with it."

Adult Unit
On 01/19/17, the hospital policy titled, "Care and Treatment Nursing- Staffing, Flexible Use of Nursing" was reviewed. The staffing patterns were established as follows:

Day Shift: 1 RN, .5 LPN, 3 MHT
Evening Shift: 1 RN, .5 LPN, 3 MHT
Night Shift: 1 RN, 2 MHT or 1 RN, 1 MHT and 1 A&R therapist.

On 01/20/17 at 2:00 p.m., staffing schedules titled, "Adult Unit Schedules" from 12/11/16 - 01/21/17 were reviewed. On these schedules, no LPN was scheduled for any Saturday and Sunday. For the weekends, staff were instructed to contact a supervisor in charge of the on-call staff. The Director of Nursing stated she kept no documentation when staff worked extended shifts, and no staff call-back information was provided.

Adolescent Unit
On 01/19/17, the hospital policy titled, "Care and Treatment Nursing- Staffing, Flexible Use of Nursing" was reviewed. The staffing patterns were established as follows:

Day Shift: 1 RN, .5 LPN, 3 MHT
Evening Shift: 1 RN, 1 LPN, 3-4 MHT
Night Shift: 1 RN, 2 MHT

On 01/20/17 at 2:00 p.m., staffing schedules titled, "Adolescent Unit Schedules" from 10/16/16 - 01/21/17 were reviewed. Staffing schedules did not show any LPNs on day shift during the the seven day work week; or evening shift on weekends. LPN listed on evening shift during the week was scheduled for 4 hours, and not on the weekend shifts.
For the weekends, staff were instructed to contact a supervisor in charge of the on-call staff. The Director of Nursing stated she kept no documentation when staff worked extended shifts, and no staff call-back information was provided.

On 01/19/17, the hospital policy titled, "Care and Treatment Nursing- Staffing, Flexible Use of Nursing" was reviewed. The policy documented the acuity system was determined through the use of the patient classification system, the patients' treatment plans and special treatment needs such as 1:1 coverage, and special safety precautions. The hospital form titled, " Nursing Needs Assessment 01/17/17"was reviewed. The form was completed daily and was used to "assist in evaluating the adequacy of 24 hour nursing personnel..." The policy stated the Program Director would review the patient census daily for each shift to ensure adequate staffing.

The following are examples of spontaneous events that would increase or shift the concentration of workload on the unit:

~Episodes requiring seclusion and restraints
The hospital 's Adult Seclusion and Restraints January through November 2016, showed
1st shift 9 episodes, 2nd shift 13 episodes, and 3rd shift 8 episodes.

Staff I and Q stated RNs cannot perform face to face assessments on the unit that they are assigned. They stated an RN from another unit would perform the face to face. They stated the on-call staff sometimes will be called to perform the assessment.

Adolescent Seclusion and Restraints January through November 2016, showed
1st shift 38 episodes, 2nd shift 34 episodes, and 3rd shift 2 episodes.

~Episodes of assaults
Adolescent Episodes of Patient Assaults January through November 2016, showed 25 episodes including pushing, hitting, biting, and spitting on staff, and hitting and kicking others patients.

~Patients requesting/demanding smoke breaks
On 01/20/17 at 12:30 p.m., during a tour on the adult unit, the surveyor observed six patients lining up by the elevator to have a smoke break. Staff Q stated MHT escort smoking patients off the unit for these breaks. A review of the "Adult Unit Patient Daily Activity Schedule" listed 1.25 hours of each day were allocated for smoke breaks.

~Return to bedroom
On both units, multiple staff stated patients, who requested, were allowed to return to their bedrooms during non-therapy times. They stated a MHT was stationed in the bedroom hallway to provide monitoring the patients in their room. During tours on 01/17/17 and 01/19/17, a MHT was seen stationed in the hall way.

~Transfers coordinated by RN
On 01/19/17 at 1:00 p.m., Staff Q stated the registered nurse manages all transfers out of the unit. Some patients were transferred to an acute facility for urgent medical conditions. Such conditions would require nursing intervention as ordered by the physician. Staff Q stated a patient had been transfered within the hour for the treatment of a blood count of 6.1 (normal 12-18 male/female range), and another patient had experienced a seizure during the night and also was transferred.

b. On 01/20/17 at 2:00 p.m., staffing schedules titled, "Adolescent Unit Schedules" from 10/16/16 - 01/21/17 were reviewed. On these schedules, agency registered nurses were scheduled for multiple shifts per week. On the adult unit for the week of 01/15/17 through 01/20/17, five different agency nurses were assigned to multiple shifts.

The Director of Nursing (DON) stated agency staff was utilized for staffing the acute units. Surveyors requested personnel files for agency staff. The DON stated the hospital did not maintain files for the agency staff, and stated the agency maintained their files. The DON stated there was no documentation of the agency staff orientation to the hospital. The DON obtained personnel files from the staffing agencies. 6 of 6 staff did not have evidence of training and competencies required by the hospital including, but not limited to: de-escalation techniques, face to face assessements, restraint and seclusion, infection control, grievance process, abuse and neglect, computer training, and emergency preparedness (fire, tornado) etc.

Based on observations, interviews, and document review, the hospital failed to ensure the registered nurses supervised and evaluated the nursing care for each patient.

Findings:

On 01/19/17 at 2:00 p.m., the hospital policy titled, "Care and Treatment Inpatient Patient Care Assignment of Patients 12/15" documented the registered nurse was ultimately responsible and accountable for patient care and allocation of available staff to meet the patient needs. Yet, on 01/19/17, Staff Q and I stated they spent 80-90% of their assigned day within the confines of the nursing station with limited unit visualization, and and prolong periods of time in the medication room with no unit visualization.
~The nursing station was partially glassed and had a view of the area in front of the elevators. The nursing station view did not include visualization of the day room and the hallway leading to the patients' bedrooms.
~The unit medication room was a locked, windowless room adjacent to the nurses station.

The nursing station provided limited view of the unit and would limit the nurse's ability to provide supervision of mental health technicians (MHT) during patient care activities.

The mental health responsibilities include assisting answering the phone, conducting group teaching session, escort to activities, sign discharge paper belongings, escort out, admission body search, monitor patient vital signs, conduct group lessons, collect satisfaction surveys, and serve patient meals.

Based on observations, interviews, and document review, the hospital failed to ensure medication was administered according to hospital policy and acceptable standards of practice.

Finding:

01/20/17 at 11:30 a.m., the suveyors observed a medication pass on the adult unit. Patient #1 had an order to receive vistaril. Staff G stated the pharmacist had not verified the medication in the automatic dispensing machine (Pyxis), and explained that when the verification has not occurred, the medication is overridden and removed from the stock drawer.

On 01/19/17 at 2:00 p.m., the hospital policy titled, "Medication Adminisrtration Guidelines 05/16" was reviewed. The policy did not document the pharmacist's role of verifying each order. The hospital policy titled, "Prescribing and Transcribing Physican's Order 05/16 " was also reviewed, this policy documented the pharmacist should verify the medication order "as soon as possible".

On 01/20/17 at 12:00 p.m., the hospital performance improvement report titled, "Medication Events October 2016" and "Medication Events November 2016" were reviewed. The October report showed the pharmacist identified and corrected 6 of10 medication error events, such as order entry errors, and wrong frequencies.

The November report documented the pharmacist identified and corrected 4 of 7 medication error events, such as medications listed on order did not match home prescriptions, old medication not discontinued, duplicate orders, and wrong drug entered into computer.

Based on observation and interviews, the hospital failed to develop and maintain a safe environment.

Findings:

On 01/17/17 at 11:53 a.m., during a tour of the bathroom near the school room, the surveyors observed patient toilets with exposed piping. The toilets were not of ligature-resistant construction.

On 01/17/17 at 11:53 a.m., Staff B stated patients were allowed to go to this bathroom unattended.

Based on observations, interviews, and document review, the hospital failed to appoint a qualified infection control preventionist.

Findings:

On 01/17/17 at 10:15 a.m., the Director of Nursing stated she was assigned the responsibilities of the hospital's Infection Control Preventionist.

On 01/19/17 at 12:15 p.m., during a review of the "Governing Board Meeting Minutes for 2016", the surveyor did not find documentation the Director of Nursing was appointed as the Infection Control Preventionist.

On 01/20/17, at 2:00 p.m., during an interview, the Director of Nursing stated she had not been appointed by the Governing Board. She stated she was not a member of any infection control national organizations. A review of her personnel file, did not show infection control training beyond the standard core infection control training that was provided to the general staff.

Based on observations, interviews, and document review, the hospital failed to ensure the infection control preventionist developed, implemented, and evaluated a system for the controlling of infections and communicable diseases.

Finding:

On 01/17/17 at 10:15 a.m., the Director of Nursing stated she was assigned the responsibilities of the hospital's Infection Control Preventionist (ICP).

On 01/17/17 at 1:30 p.m., the hospital's policy titled, "Infection Control Plan 08/14" was reviewed. The plan's focus documented that an annual Tuberculosis (TB) Risk Assessment, and a Prioritized Multi-disciplinary Risk Assessment would be performed. The ICP stated these two annual assessments had not been performed in 2016 /2017.

The hospital's policy titled, "Hand Hygiene 02/16" showed the Infection Control Preventionist (ICP) should perform periodic hand hygiene surveillance.
~The ICP's surveillance information from January through December 2016, titled, "Infection Control Results" was reviewed. The results showed the adult and adolescent unit had only one hand hygiene surveillance each in 2016. In March 2016, two hand hygiene observations/ one session were performed on the adult unit. In April 2016, ten observations/ one session were performed on the adolescent unit; of the ten observations, there was zero compliance documented. No follow-up was documented. During an interview, the ICP stated the result of 0/10 was a typographical error.
~No other hand hygiene surveillance information was provided.
~During an interview on the adolescent unit, Staff B was asked where staff washed their hands. Staff B stated hands are washed in the staff bathroom, by obtaining the key from the nursing station, and unlocking the door to enter.

On 01/17/17, during the tour, Staff B stated the patients' laundry was washed by the staff.
The policy titled, "Washer and Dryer, Use of 12/15" documented washers should be disinfected with bleach on each 11-7 shift." Staff B stated that no log was maintained for the task.

On 01/17/17, during a tour of the adolescent unit, cloth pillows were observed stacked above the washer. The pillows were not in a protective cover. Staff B could not identify if the pillows were clean or dirty.
~Linens were observed in a closet. Some of the linen was uncovered and many of the plastic wrapped bundles were opened, which left them uncovered.
~During interviews, Staff B, Staff I, and Staff G stated pillows, comforters, and blankets were cleaned by various cleaning methods. Staff B stated the comforters were washed commercially and the blankets were laundered by the facility. Staff I stated the blankets and comforters were commercially washed, and the cloth pillows washed by the facility at night. Staff G stated the blankets and comforters were commercially washed, and the cloth pillows were doubled cased.

On 01/19/2017, the hospital policy titled, "PPD Skin Testing" was reviewed. The policy documented all new employees should provide evidence of PPD testing, or a test would be administered. The policy documented existing employee would have an annual TB (tuberculosis) risk assessment, and testing.
~The ICP stated she maintained a spreadsheet for hospital clinical staff's TB skin testing. The ICP stated the personnel files would contain evidence of TB skin testing. Upon review of the spread sheets and personnel files, five of eleven hospital clinical staff failed to have documentation of current TB skin testing (Staff B, AA, BB, P,and CC).
~ The ICP stated agency staff was utilized for staffing the acute units. The ICP stated she did not include agency staff on her TB skin spread sheet. Surveyors requested personnel files for selected agency staff. The DON stated the hospital did not maintain files for the agency staff, and stated the agency maintained their files. The DON obtained the agency personnel files, and 1 of 6 staff did not have evidence of TB skin testing (Staff W).

Based on document review, hospital policy review, and interviews, the hospital failed to ensure the following specific organ, tissue, and eye procurement requirements were met:

a. address the responsibilities of the organ procurement organization (OPO) that the hospital is contracted with in its policy; (see tag A-0885).

b. provide an agreement with an eye bank; (see tag A-887).

c. provide documentation for all patient care staff education on organ, tissue and eye donation issues; (see tag A-891).

Based on document review, policy review, and staff interview the hospital failed to address responsibilities of the organ procurement in its policy.

Findings:

On 1/20/17 at 12:30 PM, an agreement with Organ Procurement Organization (OPO), LifeShare was reviewed. The hospital ' s policy titled, " Organ Donor " revised on 06/22/11, referred to an OPO by the name of " The Oklahoma Organ Sharing Network " .

On 1/20/17 at 12:30 PM, a policy titled, " Organ Donor " revised on 06/22/11 was reviewed. The policy did not reflect the responsibilities stated in the agreement between the hospital and organ procurement, LifeShare.

On 1/20/17 at 12:45 PM, a staff interview was conducted inquiring the process of a death and the communication between OPO. Staff B reported there has not been a death in the hospital in several years and unsure what the hospital ' s policy contains at this time.

Based on document review and staff interview the hospital failed to provide an agreement with an eye bank.

Findings:

On 1/20/17 at 11:19 AM, surveyor requested (second request) an eye bank agreement; none were provided.

On 1/20/17 at 12:45 PM, a staff interview was conducted. Staff B verified the hospital does not have an eye bank agreement.

Based on document review and staff interview the hospital failed to provide documentation for all patient care staff education on organ, tissue and eye donation issues.

On 1/18/17 at 2:47 PM, surveyor reviewed employee files and course objectives, no documentation showed education/training pertaining to organ donation.

On 1/20/17 at 12:30 PM, a policy and procedure document titled, " Organ Donor " revised on 06/22/11 was reviewed. The policy and procedure did not contain any information on education/training to patient care staff.

On 1/20/17 at 12:45 PM, a staff interview was conducted. Staff B reported hospital staff received training on how to care for the dying patient. Surveyor received a list of training/competencies for employees; none of the documentations showed training objectives pertaining to death or organ donation.

Based on record review and interview, there was a systematic failure by the facility to document the provision of comprehensive assessments and active treatment for each patient by facility staff providing clinical services. Specifically, the facility failed to:

I. Provide psychosocial assessments that included a social evaluation reflecting specific community resources for utilization in discharge planning; conclusions that summarized psychosocial findings and recommendations of the anticipated necessary steps for discharge to occur; and the anticipated social work roles in treatment and discharge planning for 8 of 8 sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). As a result, the treatment team did not have the necessary baseline social functioning needed for establishing treatment goals, interventions, and discharge plans by social work staff. (Refer to B108).

II. Ensure Psychiatric Evaluations (PEs) were individualized with all clinical components for 8 of 8 active sample patients (A1, A5, A17, A18, B1, B5, B6, B7, and B18). Specifically, the PEs failed to:

A. Include a general medical history of inter-current medical problems. Failure to document a medical history results in the inability to assess the impact of an acute or chronic medical condition(s) on each patient's clinical presentation and compromises the identification of pathology that may contribute to the current psychiatric illness. (Refer to B112).

B. Report memory and intellectual functioning in descriptive terms that clearly reflected each patient's level of functioning in these areas. This deficiency results in the absence of specific determinations of intellectual and memory functioning on admission for diagnosis and treatment and makes it difficult to establish objective baseline functioning for future comparisons. (Refer to B116).
C. Include patients' personal assets on which to base active treatment interventions and treatment planning. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized treatment plans and impairs the treatment team's ability to choose treatment modalities which best utilize the patient's assets in therapy. (Refer to B117).

III. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for 8 of 8 active sample patients (A1, A5, A17, A18, B1, B5, B6, B7, and B18). Specifically, the MTPs did not include:

A. Individualized and behaviorally descriptive patient strength/asset and disability/problem statements written in behavioral and descriptive terms based on clinical assessment data. (Refer to B119).

B. Observable, behavioral, and measurable short-term goals that delineated specific patient outcomes written in behavioral terms (Refer to B121).

C. Specific and individualized active treatment interventions to address patient problems and assist patients to accomplish treatment goals. (Refer to B122).

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

IV. Ensure that active treatment interventions listed on the treatment plan and were documented in the electronic medical record to reflect the patients' response to interventions that included their level of participation and understanding, behaviors exhibited during interventions, and/or specific comments for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). This failure hindered the treatment team from determining the patient's specific 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 interview, the facility failed to provide psychosocial assessments that included a social evaluation reflecting specific community resources for utilization in discharge planning; conclusions that summarized psychosocial findings and recommendations of the anticipated necessary steps for discharge to occur; and the anticipated social work roles in treatment and discharge planning for 8 of 8 sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). As a result, the treatment team did not have the necessary baseline social functioning needed for establishing treatment goals, interventions, and discharge plans by social work staff.

Findings include:

A. Record Review
1.A review of the facility's policy titled, "Screening / Assessment, Psychosocial Assessment," revised 3/13/15, stipulated that the facility, " ... completes a thorough assessment of patients to determine individual needs, treatment objectives, course of treatment, and discharge planning issues." Additionally, under "Procedure: II-AA," this policy states that, "The complete Psychosocial Assessment contains vital information for the determination of course of treatment for the patient. The Psychosocial Assessment contains at the minimum the following information ... Current support system and community resources." The facility failed to follow its own policy regarding community resources.

2. Patient A1 was admitted on 1/14/17 with a diagnosis of "Major depressive disorder ...' The psychosocial assessment, dated 1/15/17, did not address or identify community resources or previously used resources. The section titled "Interpretive Summary with Recommendations" did not include a summary of findings based on data collected for the psychosocial assessment. This section only included the following brief statement: "to set up outpatient service for [her] after [her/his] discharge." In addition, the assessment did not describe the anticipated social work role in treatment and discharge planning.

3. Patient A2 was admitted on 1/10/17 with a diagnosis of "Major Depressive Disorder recurrent without psychosis." The psychosocial assessment, dated 1/11/17, did not address or identify community resources or previously used resources. The "Interpretive Summary with Recommendations" did not contain a summary of findings based on data collected for the psychosocial assessment and only restated the non-specific presenting problem of, "SI [Suicidal Ideation] w/plan, depression, anxiety, hx [history] physical & sexual abuse." Except for "family therapy," the anticipated social worker roles in treatment and discharge planning were not clearly defined. The following identical and/or similarly worded statement was also documented for Patient A3 and A4 - "Hospitalization to include: individual, group, rec [recreation] therapy, Tulsa Public School, medication management, and education." The only mention of discharge information for this patient was, "to evaluate if pt. [patient] will benefit from a step down residential treatment."

4. Patient A3 was admitted on 1/12/17 with diagnoses of "Bipolar Disorder, without psychotic features ... opiate dependent." The psychosocial assessment, dated 1/13/17, did not address or identify community resources or previously used resources. The "Interpretive Summary with Recommendations" section of the assessment did not contain a summary of findings based on data collected for the psychosocial assessment. In addition, this section did not contain a clear description regarding what the anticipated social worker roles in treatment and discharge planning were and included treatment to be provided by other disciplines such as "rec [recreation] therapy" and "medication management."

5. Patient A4 was admitted on 1/9/17 with a diagnosis of "Major Depressive Disorder, recurrent severe without psychosis." The psychosocial assessment, dated 1/10/17, did not address or identify community resources or previously used resources. The "Interpretive Summary with Recommendations" section of the assessment did not contain a summary of findings based on data collected for the psychosocial assessment. In addition, this section did not contain a clear description regarding the anticipated social worker roles in treatment and discharge planning.

6. Patient B1 was admitted on 1/12/17 with a diagnosis of "Bipolar I Disorder ... w/o [without] psychosis ..." The psychosocial assessment, dated 1/13/17, did not address or identify community resources or previously used resources. The "Interpretive Summary with Recommendations" section of the assessment did not describe the anticipated social work role in treatment and discharge planning.

7. Patient B2 was admitted on 1/8/17 with diagnoses of "Opiate withdrawal ... Major Depressive Disorder ... w/o psychosis ..." The "Interpretive Summary with Recommendations" section of the psychosocial assessment, dated 1/8/17, did not contain a summary of findings based on data collected for the psychosocial assessment. In addition, this section did not contain a clear description regarding the anticipated social worker roles in treatment planning. This section noted, "Inpt [Inpatient] hospitalization to include individual, family focus, group therapy; rehab [rehabilitation] groups and medication management ..."

8. Patient B3 was admitted on 1/12/17 with diagnoses of "Opiate withdrawal ... Major Depressive Disorder ... w/o psychosis ..." The "Interpretive Summary with Recommendations" section of the psychosocial assessment, dated 1/13/17, did not contain a summary of findings based on data collected for the psychosocial assessment. In addition, this section did not contain a clear description regarding the anticipated social worker roles in treatment and discharge planning. This section noted, "Inpatient recommended at this time to include med [medication] management, process group, rehab [rehabilitation] group, individual ..."

9. Patient B4 was admitted on 1/12/17 with diagnoses of "Schizoaffective Disorder, Bipolar type; other stimulant Dependence ..." The psychosocial assessment, dated 1/13/17, did not clearly address or identify community resources or previously used resources. The "Interpretive Summary with Recommendations" section of the psychosocial assessment, dated 1/13/17, did not contain a summary of findings based on data collected for the psychosocial assessment. In addition, this section did not contain a clear description regarding the anticipated social worker roles in treatment and discharge planning. This section noted, "Inpt [Inpatient] hospitalization to include individual, family focus, group therapy ..."


B. Interview

During an interview with the Director of Social Work on 1/18/16 at 3:20 p.m., the psychosocial assessments for Patients A1, A2, A3, and A4 were discussed. She acknowledged that the Psychosocial Assessments did not contain a section that identified community resources based on the patient's needs or information regarding resources previously used. She stated that they previously had information regarding community resources included on the assessment but agreed that it was not included on the psychosocial assessment in the new electronic medical record. She acknowledged the findings regarding the lack of sufficient conclusions reflecting a summary of psychosocial data collected. She also did not dispute findings that the "Interpretive Summary with Recommendations" section of the psychosocial assessment failed to clearly identify anticipated treatment interventions and discharge plans to be addressed by social work staff.

Based on record review and staff interview, the facility failed to document a descriptive neurological examination that included what tests were performed to assess neurological functioning of 8 of 8 sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). This failure to document current neurological status precludes accurate diagnosis and future comparative reexamination to measure any change in baseline functioning.

Findings include:

A. Record Review

The following Physical Examinations (dates of examination in parentheses) were reviewed. A1 (1/15/17), A2 (1/11/17), A3 (1/12/17), A4 (1/10/17), B1 (1/13/17), B2 (1/9/17), B3 (1/13/17), and B4 (1/13/17). This review revealed that all examination stated, "Cranial Nerves: Normal." There was no evidence to show which cranial nerves were examined or specific tests used to determine findings.

B. Interview

During an interview with the Medical Director on 1/18/17 at 10:15 a.m., she acknowledged that evaluation of the cranial nerves did not include evidence of tests or information to substitute the interpretation that cranial nerves were normal for the active sample patients.

Based on record review and interview, the facility failed to ensure that Psychiatric Evaluations (PE) included a general medical history of inter-current medical problems for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Failure to document a medical history results in the inability to assess the impact of an acute or chronic medical condition(s) on each patient's clinical presentation and compromises the identification of pathology that may contribute to the patient's current psychiatric illness.

Findings include:

A. Records Review

The following Psychiatric Evaluations (PEs) titled, "Evaluation" by the facility (dates of examination in parentheses) were reviewed. A1 (1/15/17), A2 (1/10/17), A3 (1/13/17), A4 (1/10/17), B1 (1/13/17), B2 (1/8/17), B3 (1/13/17), and B4 (1/13/17). This review revealed that none of the PEs documented a medical history.

B. Interview

During an interview with the Medical Director on 1/18/17 at 10:15 a.m., the psychiatric evaluations for Patients A1, A2, A3, and A4 were reviewed. She acknowledged that the medical history was missing for each of these patients. She agreed that this information is important for treatment and to determine whether medical conditions are contributory to patients' psychiatric condition.

Based on record review and interviews, the facility failed to ensure that psychiatric evaluations (PEs) for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4) reported memory and intellectual functioning in descriptive terms that clearly reflected each patient's level of functioning in these areas. Without more detailed information about a patient's orientation, level of intellectual functioning, and/or memory functioning, it is not possible to know the specific extent of the patient's capacity or impairment so that appropriate treatment modalities can be chosen, and/or so that changes in response to treatment can be measured. This deficiency results in the absence of specific determinations of intellectual and memory functioning on admission for diagnosis and treatment and makes it difficult to establish objective baseline functioning for future comparisons.

Findings include:

A. Record review

The following Psychiatric Evaluations (PEs) titled, "Evaluation" by the facility (dates of examination in parentheses) were reviewed: A1 (1/15/17), A2 (1/10/17), A3 (1/13/17), A4 (1/10/17), B1 (1/13/17), B2 (1/8/17), B3 (1/13/17), and B4 (1/13/17). This review revealed the following findings:

1. Patient A1 - The Psychiatric Evaluation did not show evidence of evaluation and estimation of patient's memory or intellectual functioning.

2. The Psychiatric Evaluation for Patients A2, A3, A4, B1, B2, B3, and B4 all contained the following identical information documented; 'Memory: No memory impairment" and "Intellectual functioning: Average." There was no evidence to show how the findings were measured or determined.

B. Interview

During an interview with the Medical Director on 1/18/17 at 10:15 a.m., the Psychiatric Evaluations for Patients A1, A2, A3, and A4 were reviewed. She did not dispute the finding that the PEs did not included specific information reflecting how findings for memory and intellectual functioning were determined. She agreed that there was insufficient baseline information for future comparisons.

Based on record review and staff interview, the facility failed to provide a Psychiatric Evaluation that included the patients' personal assets on which to base active treatment intervention and treatment planning for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). The patient strengths identified were not individualized or descriptive of each patient's attributes, skill, and/or interests. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized treatment plans and impairs the treatment team's ability to choose treatment modalities which best utilize the patient's assets in therapy.

Findings include:

A. Record review

The following Psychiatric Evaluations (PEs) titled, "Evaluation" by the facility (dates of examination in parentheses) were reviewed for patient assets. A1 (1/15/17), A2 (1/10/17), A3 (1/13/17), A4 (1/10/17), B1 (1/13/17), B2 (1/8/17), B3 (1/13/17), and B4 (1/13/17). This review revealed the following findings:

1. Patient A1's Psychiatric Evaluation under the section titled "Assets" documented "refused to answer." There was no documented evidence that another attempt had been made to obtain information regarding this patient's assets.

2. Patient A2's, A4's, and B2's Psychiatric Evaluation, under the section titled "Assets" contained the following non-specific asset: "Healthy." This statement was not individualized and failed to provide specific information regarding the usefulness of this asset in psychiatric treatment and treatment planning.

3. Patient A3's Psychiatric Evaluation under the section titled "Assets" contained the following non-specific patient asset: "Still feels attachment to some family members." Although individualized, the statement failed to provide specific information regarding which family members or how they would be helpful in the treatment and/or aftercare for the patient.

4. Patient B1's, B3's, and B4's Psychiatric Evaluation under the section titled "Assets" contained the following non-specific patient assets: "Average intelligence, fair insight, grossly good physical health" that were not individualized and did not provided descriptive information how they would be meaningful for psychiatric treatment and treatment planning.

B. Interview

During an interview with the Medical Director on 1/18/17 at 10:15 a.m., the psychiatric evaluations were reviewed for patient assets to use in treatment. The Medical Director acknowledged that the psychiatric evaluations for the active sample patients A1, A2, A3, and A4 did not include an inventory of specific and descriptive patient assets that could be used in treatment planning and treatment.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) which were based on individualized and behaviorally descriptive patient strengths/assets and disabilities/problems for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). Failure to identify and incorporate patient strengths and disabilities into the formulation of therapeutic interventions in the Master Treatment Plan diminishes the effectiveness of treatment interventions, and can hamper the patient's achievement of treatment goals.

Findings include:

I. Patient Assets/Strengths

A. Record Review

1. The facility's policy 304.19, titled "Care and Treatment Patient Care Treatment Planning," last reviewed 3/13/15, stipulated that, "Treatment planning identifies treatment care and services based on each patient's unique needs and goals ... The preliminary treatment is a clinical formulation based on the significant findings of the initial and subsequent multi-disciplinary assessments and provides a basis for development of the Master (interdisciplinary) treatment plan ... Initial screening includes clinical interpretations from assessments, strengths, weaknesses, diagnostic formulations, and treatment focus ... Reflects the patient's clinical needs and condition and identifies functional strengths, limitations and goals." This policy did not provide specific guidance to clinical staff regarding the formulation of an inventory of unique patient's strengths/assets that could be used in treatment planning.


2 The facility's Master Treatment Plan form included a pre-printed list of items to identify patient strengths/limitations. The list also included an item labeled "other" where additional assets/strengths could be written on the form.

3. Four (4) of 8 active sample patients (A1, A2, A3 and A4) had identical "strengths/limitations" identified in their pre-printed list of items on page 1 of their Master Treatment Plan.

4. There were no patient assets/strengths identified on admission incorporated in the Master Treatment Plan for 8 of 8 active sample patients: A1 ( MTP dated 1/16/17); A2 ( MTP dated 1/10/17); A3 ( MTP dated 1/13/17); A4 ( MTP dated 1/11/17) and B1 ( dated MTP 1/15/17); B2 (dated MTP 1/11/17); B3 (dated MTP 1/15/17); B4 (dated MTP 1/15/17).

5. Patient A1 (admitted 1/14/17; last MTP 1/16/17): The MTP dated 1/16/17; identified strengths/limitations from pre-printed check list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-fair." "Family stability-good." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-fair." "Ability to read-good." "Ability to write-good." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

6. Patient A2 (admitted 1/10/17; last MTP 1/10/17): The MTP dated 1/10/17; identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-fair." "Family stability-good." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-fair." "Ability to read-good." "Ability to write-good." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

7. Patient A3 (admitted 1/12/17; last MTP 1/13/17): The MTP dated 1/13/17; identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-fair." "Family stability-good." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-fair." "Ability to read-good." "Ability to write-good. There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

8. Patient A4 (admitted 1/8/17; last MTP 1/11/17): The MTP dated 1/11/17; identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-fair." "Family stability-good." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-fair." "Ability to read-good." "Ability to write-good." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

9. Patient B1 (admitted 1/12/17; last MTP 1/15/17): identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-good." "Family stability-fair." "Capacity to learn-excellent." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-fair." "Ability to read-excellent." "Ability to write-excellent." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

10. Patient B2 (admitted 1/8/17; last MTP 1/11/17): identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-good." "Family stability-fair." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-good." "Ability to read-good." "Ability to write-good." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

11. Patient B3 (admitted 1/12/17; last MTP 1/15/17): identified strengths/limitations from pre-printed list "Social skills-good." "Receptive language skills-good." "Expressive language skills-good." "Capacity for independence-good." "Family stability-good." "Capacity to learn-good." "Involvement in hobbies/leisure activities-fair." "Capacity for insight-good." "Ability to read-good." "Ability to write-good." There was no evidence how the assessments were carried or how the identified strengths/limitations were to be used to support the patient's treatment goals.

12. Patient B4 (admitted 1/12/17 last MTP 1/15/17): identified strengths/limitation from pre-printed list "Social skills-poor." "Receptive language skills-fair." "Expressive language skills-fair." "Capacity for independence-fair." "Family stability-poor." "Capacity to learn-fair." "Involvement in hobbies/leisure activities-poor." "Capacity for insight-fair." "Ability to read-fair." "Ability to write-fair." There was no evidence how the assessments were done or how the identified strengths/limitations were to be used to support the patient's treatment goals.

B. Interviews

1. In an interview on 1/18/17 at 11:30 a.m., with RN1, after reviewing the sample patient's plans, the RN1 acknowledged that the treatment plans did not include the patient assets that had been identified in the assessments

2. In an interview on 1/18/17 at 1.25 p.m., with MD1, after reviewing the treatment plans for Patient B1 and B2, he agreed that the Master Treatment Plans did not adequately identify and use patient strengths/assets and the interventions need to be improved.


II. Patient Disabilities/Problems

A. Record Review

1.The facility's policy 304.19 titled "Care and Treatment Patient Care Treatment Planning" reviewed 3/13/15, stipulated that, "Treatment planning identifies treatment care and services based on each patient's unique needs and goals, severity of disease, condition, impairment or disability as identified the various assessments ..." This policy did not provide specific guidance to clinical staff regarding the formulation of an inventory of unique patient's disabilities/problems based data from the psychiatric evaluation and various clinical assessments.



2. Patient A1's MTP, dated 1/16/17, included the following psychiatric problem statement: "Suicidal/homicidal ideation with plan/attempt and depression." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/15/17, noted the following description of the patient's problem, "Increased anger and aggression towards a peer....' I hit [him/her] square in the face because [s/he] said my mom had cancer'."

3. Patient A2's MTP dated 1/10/17 included the following psychiatric problem statement: "Suicidal/homicidal ideation with plan/attempt and depression." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/10/17, noted the following "Physically abused... has nightmares and flashbacks... panic attacks... had one yesterday... attempted suicide more than 10 times... Started having suicidal thoughts on Saturday" [S/he] was going to buy a gun or overdose ..."

4. Patient A3's MTP, dated 1/13/17, included the following psychiatric problem statement: "Suicidal ideation with plan/attempt and depression." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/13/17, noted the following description of the patient problem: "Patient has been shooting up heroin and using Meth. [sic] ... has been robbing homes to get money for heroin... feels hopeless and helpless ... has mood swings ...there is really no time when [s/he] is not high."

5. Patient A4's MTP, dated 1/16/17, included the following psychiatric problem statement: "Suicidal/homicidal ideation with plan/attempt and depression." There were no behavioral descriptions reflecting how this patient manifested the problem based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/10/17, noted the following description of the patient problem: "Patient states starting 6 months ago [s/he] began cutting herself. Started having suicidal thoughts in mid-December. [S/he] attempted this time by cutting as deep as [s/he] could ... has random flashback about abuse of [his/her] mother and [his/her] father... gets really angry when around places that reminds [his/her] of [his/her] father ... punch walls when angry and nearly broke [his/her] hand ... gets into physical fights ..."

6. Patient B1's MTP, dated 1/15/17, included the following psychiatric problem statement: "Unstable mood - AEB [As Evidenced By]: "Unstable mood with anger and suicidal thoughts." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation dated 1/13/17 noted the following " ... frequent depressive episodes for years ... feeling down in the dumbs, hopeless ... no reason to go on ... contemplating a suicide by using a gun he owns ... states that [s/he] has thoughts about jumping off high-rise buildings for some time."

7. Patient B2 MTP, dated 1/11/17, included the following psychiatric problem statement: "use of opiates" There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/8/17, noted the following " ... gets opiates off the street, started Lortab 10 years ago, changed to oxy [sic] ... gets depressed at times when I have nothing, feels hopeless and helpless ... has trouble sleeping when [s/he] is off opiates ... has a panic attack ... no particular reason ... has had depression for about a year."

8. Patient B3 MTP, dated 1/15/17, included the following psychiatric problem statement: "Chronic pain r/t [sic] degenerative joint disorder." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation, dated 1/10/17, noted the following "Physically abused... has nightmares ... has been using opiates for years ... has been known to have a long history of alternating bouts of depression with frequent mood swings, rage and mania ... last manic episode was a month ago."

9. Patient B4 MTP, dated 1/15/17, included the following psychiatric problem statement: "Unstable moods, voices, visions and SI [sic]." There were no behavioral descriptions reflecting how this patient manifested the problem statement based on clinical assessment data. The patient's Psychiatric Evaluation dated 1/13/17 noted the following " A long history of alternating bouts of depression with frequent mood swings, rage and mania ... has been depressed on and off for years, feeling down in the dumps, hopeless, helpless, worthless, no reason to go on, difficulty falling and staying asleep, thinking about suicide on and off for years, having attempted suicide a few times in the past by OD [sic] and cutting ... increasingly tired, and fatigue, loss of interest and motivation and no reason to go on."

Based on record review and interview, the facility failed to develop Master
Treatment Plans (MTPs) which included observable, behavioral, and measurable goals that delineated specific outcome behaviors for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). These deficient goal statements hinders the ability of the team to individualize treatment and to measure change in the patients' consequences to treatment interventions.

Findings include:

A. Record Review

1. The facility's policy 304.19, titled "Care and Treatment Patient Care Treatment Planning", last reviewed 3/13/15, stipulated that, "Master Treatment Plan: Contains specific measurable goals that the patient must achieve to attain, maintain and/or reestablish emotional and/or physical health as well as maximum growth and adaptive capabilities."

2. The facility used identical pre-printed treatment plan forms which resulted in the selection of identical treatment goals for 4 of 8 active sample patients (A1, A2, A3 and A4) and similar goals for 4 of 8 active sample patients (B1, B2, B3 and B4) regardless of individual problems and needs. The listed goals also had no target dates for expected achievement.

3. The facility failed to identify discharge planning goals in the MTP for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4).



4. The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/17/17), A2 (1/10/17), A3 (1/13/17), A4 (1/11/17), B1 (1/15/17), B2 (1/11/17), B3 (1/15/17) and B4 (1/15/17). This review revealed that the MTPs included but not limited to the following short-term goals (STG) that were not stated in observable, behavioral, and measurable terms with an alternative or replacement behavior that would show the patient's increased level of functioning. Several patients had identical STGs goals despite having different presenting psychiatric symptoms.

1. Four (4) patients (A1, A2, A3, and A4) had the following pre-printed identical STGs: "1. Pt will ID [identify] and process 3 triggers for suicide/homicidal ideation and increased depression. 2. Pt will ID [identify] and process 3 positive coping skills for managing suicidal/homicidal ideation and depression. 3. Pt will report and exhibit behaviors consistent with elimination of or decrease frequency, intensity and intent of suicidal/homicidal ideations and decrease in level of depression."

Short-term goal: 1 and 2. These goals were not stated in observable, behavioral, and measurable terms reflecting the method(s) to be utilized for identifying and processing triggers for suicide/homicidal ideation and increased depression. It failed to reflect how the patient would be identifying (saying and/or doing to) to eliminate, reduce, and/or improve his/her presenting problem.

Short-term goal: 3. This goal was stated as staff expectation/compliance in treatment rather than behavior outcomes to evaluate whether the patient's stated problem has been reduced/resolved "Pt will report and exhibit behaviors consistent with elimination of or decrease frequency, intensity and intent of suicidal/homicidal ideations and decrease in level of depression." No results found to determine whether patient was sharing his/her feelings; thus not a measurable goal.

2. Two (2) patients (B1 and B2) had the following pre-printed identical short-term goal: "Pt will process feelings daily."

Short-term goal: This goal was not written as observable, behavioral and measurable terms with an alternative or replacement behavior that would show the patient's increase level of functioning.

3. One (1) patient (B3) had the following pre-printed short-term goals. 1. "To stop drug use." 2. "[Name of patient] will clarify 3 skills that she can engage to stop drug use prior discharge."

Short-term goal: 1 and 2 were not stated in behavioral terms reflecting what the patient would be doing or saying, such as stating he/she has a plan, knows alternative to pain control.

C. Interview

In an interview on 1/17/17 at 2: 20 p.m. with the Inpatient Unit Director, the MTPs for patients B1, B2, B3, and B4 were reviewed. She agreed that goal statements were identical or similarly worded on the MTPs.

Based on record review and interview, the facility failed to develop individualized treatment plans that clearly delineated active treatment interventions to address specific patient problems and assist patients to accomplish treatment goals for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Treatment interventions on the pre-printed Master Treatment Plan (MTP) listed routine generic discipline functions that were written as active treatment interventions. In addition, activity therapist interventions were absent. This failure results in lack of guidance for staff in providing individualized approaches to patient care that is purposeful and goal directed.

Findings include:

A. Record Review:

1. The facility's policy 304.19, titled, "Care and Treatment Patient Care Treatment Planning" reviewed 3/13/15, stipulated that, " ... "Master Treatment Plan: Specifies the interventions and frequency of treatment modalities to meet individual goals and objectives ... Ensures that therapeutic activities are directly related to treatment plan goals ... If necessary, the plan includes specialized rehabilitation services to restore or maintain the functional abilities of individuals with physical, cognitive, social, leisure, or sensory perceptual impairments or maladaptive of problem behaviors ... Activity services when provided are incorporated into the treatment plan to provide a consistent and well-structured framework."


2. The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (1/16/17), A2 (1/10/17), A3 (1/13/17), A4 (1/11/17), B1 (1/15/17), B2 (1/11/17), B3 (1/15/17) and B4 (1/15/17). This review revealed that the Master Treatment Plans did not include individualized active treatment interventions but contained routine discipline functions (such as "prescribe," "monitor," and "administer medication") written as active treatment interventions to be delivered by the physician and registered nurse. The interventions to be delivered by therapists were not individualized and were mostly generic statements. Most intervention statements were identical or similarly worded.

1. Discharge planning interventions in the MTP for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4) were absent. This failure makes it difficult to determine what role social work plays in the treatment and recovery of the patients.

2. Therapeutic activities interventions to be delivered by activity therapists were not included in the MTP for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4).

3. Eight (8) patients (A1, A2, A3, A4, B1, B2, B3 and B4) had the following identical/similarly worded generic and routine physician interventions. "[Name of physician] will prescribe medications when needed, monitor for potential side effects, and educate the family and patient about the benefits of taking the medication." "Psychiatrist will meet with patient 7x/week [sic] to reduce anger/aggression and depression." "Educate the patient about the benefits of taking the medication, meet with the patient 7x/week [sic] to reduce anger/aggression and depression." Part of the intervention statement was an active treatment intervention but it did not state how the interventions would be delivered (group/individual sessions), duration of contact with the patient, and method employed in the reducing of anger/aggression and depression.

4. Three (3) patients (B1, B2 and B4) has the following identical generic routine physician intervention. The only difference was the rationale for the medication order. "[Name of physician] will meet with patient on a daily basis to prescribe medications, evaluate effectiveness and/or side effects of prescribed medication for 1[sic] week to assist in eliminating "mood instability," "anger and suicidal ideation," "reduce risk of drug use," "stabilize mood and psychosis."

5. Seven (7) patients (A1, A2, A3, A4, B1, B2 and B4) had the following identical/similarly worded therapist interventions. "Therapist will assist the patient w/understanding [sic] the nature of the behavioral problems," "will facilitate group process, and will teach new coping skills," "will conduct family therapy or family focused therapy to help patient meet Tx [Treatment] goals," "patient will be seen for 3 hrs. /wk. [sic] of individual and/or family therapy," patient will be seen for 3hr/wk. [sic] of process group therapy per [sic] week." "TF-CBT [sic] or Solution-Focused will be utilized to reduce anger/aggression and depression."

6. One (1) patient (B3) Master Treatment Plan did not have a therapist intervention.

7. Seven (7) patients (A1, A2, A3, A4, B1, B2 and B4) had the following identical/similarly worded nursing intervention: "Nurse will administer meds (medication) as prescribed, will monitor for side effects, & [and] answer questions patient may have about their meds. Also, will educate pt. (patient) on medications each shift daily 7x/week to reduce anger/aggression and depression. The "educate patient" part of the intervention statement was a treatment intervention but failed to include the content of the education, knowledge, side effects, benefits of specific medication(s), how the intervention will be delivered (group or individual sessions), and duration of the contact.

8. One (1) patient (B4) had the following generic routine nursing intervention: "[Name of nurse] will administer PRN (as needed) and routine meds (medications) for pain levels > [greater than] 3 as needed. Monitor for increase in vital signs, document medication administration and education at each opportunity."

C. Interview

In an interview on 1/17/17 at 2:10 p.m. with the Inpatient Unit Director, the MTPs for Patients B1, B2, B3, and B4 were reviewed. She agreed the interventions were not individualized.

Based on record review and interview, the facility failed to ensure that active treatment interventions listed on the treatment plan and were documented in the electronic medical record to reflect the patients' response to interventions that included their level of participation and understanding, behaviors exhibited during interventions, and/or specific comments for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, this deficient practice included interventions assigned to registered nurses, mental health workers, and therapists for 2 of 8 active sample patients (A2 and A4). This failure hindered the treatment team from determining the specific 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 master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (1/16/17); A2 (1/10/17); A3 (1/13/17); A4 (1/11/17); B1 (1/15/17); B2 (1/11/17); B3 (1/15/17); and B4 (1/15/17). This review of treatment notes in the electronic medical record revealed the following findings:

1. RN Interventions - There was insufficient documentation notes regarding the following patients' response to intervention, including their level of participation, level of understanding, and behaviors exhibited during the following assigned interventions:

a. Patients A1, A2, A3, and A4, all had following treatment intervention assigned to registered nurses: " ... will educate pt. [patient] on medications each shift daily 7x/week to reduce anger/aggression and depression."

b. Patients B1 had the following treatment intervention assigned to registered nurses: "The RN will educate pt. [patient] on medication plus any possible side-effects, each shift, daily for 1 week to assist pt. in eliminating his unstable mood, angry outburst, and suicidal ideations."

c. Patients B2 had the following treatment intervention assigned to registered nurses: " ... the RN will educate on medications that the patient is taking to reduce risk of drug use."

d. Patients B3 had the following treatment intervention assigned to registered nurses: " ... Med. [Medication] education ..."

e. Patients B4 had the following treatment intervention assigned to registered nurses: "The RN will educate patient on the effects/ side effects of medications, to assist pt. [patient] in stabilizing mood and A/V Hals [Hallucinations]."

2. Therapists Interventions - There was insufficient documentation notes regarding Patients A2 and A4 response to a group intervention. The treatment notes, dated 1/12/17, documented that a group was conducted on 1/9/17 and stated, " ... met with them and did an animal assisted group, with the help of coloring pictures of different animals ... asked them to talk about the person or persons they keep them anchored ..." The documentation failed to include these patients' response to the group intervention, their level of participation and understanding, behaviors exhibited, and/or specific comments made by these patients during the intervention.

3. MHT Interventions - There was insufficient documentation regarding the following patients' response to intervention, including their level of participation, level of understanding, and behaviors exhibited during the following group interventions:

a. Patient A1, A2, A3, A4, B1, all had the following identical or similarly worded treatment intervention assigned to mental health technicians: "MHT will facilitate four rehab [rehabilitation] groups per week by providing psychoeducational groups to improve coping skills to reduce anger/aggression and depression."

b. Patient B2 had the following treatment intervention assigned to mental health technicians: "MHT will facilitate four rehab [rehabilitation] groups for one week to reduce risk of drug use."

c. Patient B4 had the following treatment intervention assigned to mental health technicians: "MHT will facilitate 4 rehab [rehabilitation] groups daily, to assist patient in learning healthy ways to cope with triggers, leading to unstable mood, A/V hals [sic] [hallucinations], and suicidal ideations prior to discharge."

B. Interviews

1. In an interview on 1/18/17 at 3:50 p.m., with the Director of Nursing, treatment notes for RN interventions on MTPs were discussed. She did not dispute the finding that documentation in the electronic medical record failed to include information about specific information provided patients regarding their medication, their level of participation, specific behaviors exhibited, and/or specific comments made during the intervention.

2. In a discussion on 1/19/17 at 10:45 a.m. with the Director of Social Work, treatment notes for Patient A2 and A4 were discussed. She agreed that documentation regarding these patients' response to the group intervention was missing.

Based on observation, interview, and record review, the facility failed to ensure sufficient numbers of registered nurses and qualified activity therapist staff to document and provide active treatment interventions. The facility failed to:

I. Assign one staff with a master's degree in social work (MSW) to fulfill the duties, functions, and responsibilities related to oversight of the quality and appropriateness of social work practice. This deficient practice results in no supervision and monitoring of the quality of the psychosocial assessments, discharge planning, and other social work practices by a MSW. (Refer to B154).

II. Provide adequate number of Registered Nurses (RN) on all three shifts [days, evenings, and nights] on the Adolescent and Adult units for seven days of staffing requested, which included the first day of the survey. This failure creates a potential safety risk for both the Adult and Adolescent Units. (Refer to B150).

III. Provide sufficient trained therapeutic activities staff to provide and document active treatment for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, there was no documented Activity Therapy Program, no activity therapy assessments to determine appropriate therapeutic activities based on each patient's need, and no qualified activity therapist to complete assessments and provide active treatment interventions. This failure results in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities. (Refer to B122, B139, and B158 I-II).

IV. Ensure that the Director of Nursing and the Director of Social Work (provided oversight for therapeutic activities) monitored and took the needed corrective actions to ensure that sufficient clinical staff members were available to perform the required discipline duties and responsibilities. (Refer to B148, B154, and
B158).

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

I. Provide sufficient trained therapeutic activities staff to provide and document active treatment for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, there was no documented Activity Therapy Program, no activity therapy assessments to determine appropriate therapeutic activities based on each patient's need, and no qualified activity therapist to complete therapeutic activities assessments and provide active treatment interventions. (Refer to B122 and B158 I).

II. Provide documented evidence showing paraprofessional staff competency to provide therapeutic activities. Specifically, Mental Health Technicians (MHTs) provided most of the therapeutic activities titled "psychoeducational or rehabilitation" groups. MHTs did not have documented evidence that showed training to facilitate these groups, which they were assigned to lead. (Refer to B158 II).

The failures above result in the lack of a comprehensive therapeutic activities program and a lack of active treatment by qualified activity therapists that is sufficient in frequency and intensity necessary to impact patients' improvement, potentially leading to patients being hospitalized without sufficient activities to assist in their recovery.

Based on interviews, record reviews, and document reviews, the Medical Director failed to:

I. Ensure Psychiatric Evaluations (PEs) were individualized with all clinical components for 8 of 8 active sample patients (A1, A5, A17, A18, B1, B5, B6, B7, and B18). Specifically, the PEs failed to:

A. Document a descriptive neurological examination that included what tests were performed to assess neurological functioning. This failure to document current neurological status precludes accurate diagnosis and future comparative reexamination to measure any change in baseline functioning. (Refer to B109).

B. Include a general medical history of inter-current medical problems. Failure to document a medical history results in the inability to assess the impact of an acute or chronic medical condition(s) on each patient's clinical presentation and compromises the identification of pathology that may contribute to the current psychiatric illness. (Refer to B112).

C. Report memory and intellectual functioning in descriptive terms that clearly reflected each patient's level of functioning in these areas. This deficiency results in the absence of specific determinations of intellectual and memory functioning on admission for diagnosis and treatment and makes it difficult to establish objective baseline functioning for future comparisons. (Refer to B116).

D. Include patients' personal assets on which to base active treatment intervention and treatment planning. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized treatment plans and impairs the treatment team's ability to choose treatment modalities which best utilize the patient's assets in therapy. (Refer to B117).

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for 8 of 8 active sample patients (A1, A5, A17, A18, B1, B5, B6, B7, and B18). Specifically, the MTPs did not include:

A. Individualized and behaviorally descriptive patient strength/asset and disability/problem statements written in behavioral and descriptive terms based on clinical assessment data. (Refer to B119).

B. Observable, behavioral, and measurable short-term goals that delineated specific patient outcomes written in behavioral terms (Refer to B121).

C. Specific and individualized active treatment interventions to address specific patient problems and assist patients to accomplish treatment goals. (Refer to B122).

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care; potentially resulting in patient's active treatment needs not being met.

Based on observation and record review, it was determined that the Director of Nursing failed to provide adequate oversight to ensure quality nursing services. Specifically, the Director of Nursing failed to monitor and take corrective action to:

I. Ensure the Master Treatment Plans (MTPs) had adequately developed and individualized nursing treatment interventions, with a specific purpose and/or focus, based on the assessed needs of 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). In addition, nursing interventions lacked duration and method of delivery (individual, group). These deficiencies resulted in treatment plans that failed to reflect a comprehensive and individualized nursing approach to treatment. (Refer to B122).

II. Ensure that nursing interventions listed on the treatment plan and were documented in the electronic medical record to reflect the patients' response to interventions reflecting their level of participation and understanding, behaviors exhibited during interventions, and specific comments for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). This failure hinders the treatment team from determining the patient's response to nursing 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 B124).

III. Provide adequate number of Registered Nurses (RN) on all three shifts [days, evenings, and nights] on the Adolescent and Adult units for seven days of staffing requested, which included the first day of the survey. This failure creates a potential safety risk for both the Adult and Adolescent Units. (Refer to B150).

Based on observation, document review, and interview, the Nursing Director failed to provide adequate number of Registered Nurses (RN) on all three shifts [days, evenings, and nights] on the Adolescent and Adult units for seven days of staffing requested, which included the first day of the survey. This failure creates a potential safety risk for both the Adult and Adolescent Units.

Findings include:

A. Observation

Observation occurred on the Adult Psychiatric Unit on 1/17/17 from 1:30 p.m. to 2:00 p.m. RN I left the unit unattended without an RN licensure on the unit. RN 1 was asked upon return, she stated she was called to do a "face to face on another unit." The RN duties included doing nursing assessments, admitting and discharging patients, attending treatment planning meetings, charting nursing notes, handling psychiatric emergencies, going to other units to conduct face-to-face assessments. Therefore, the RN was not involved in any structured active treatment, and was able to provide little or no supervision of the License Practical Nurse (LPN) and the Mental Health Technicians (MHT) working with patients with acute psychiatric problems.

B. Document Review

I. Adult Psychiatric Unit

1. An analysis of the Staffing Data collected on the second day of survey (1/18/17) and for the week of 1/11/17 through 1/17/17 revealed that the census ranged from 10 - 14 patients per day. There was 1 RN assigned with 3 MHT and an LPN for 4 days, working from 11:00 a.m. to 7:00 p.m. on the day and evening shifts. This resulted in no consistent additional licensed staff available to provide assistance in cases of emergencies and for the RN's meals and breaks. Additionally, because of the RN workload, there was sporadic time available to provide ongoing interactions with patients.

2. A review of the Needs Assessment document revealed a high patient acuity that would require consistent, and ongoing oversight by an RN. The patient acuity on this unit required an RN to be available to provide active treatment interventions and clinical supervision of paraprofessional staff. The Needs Assessment document completed revealed a census of 10 patients with the following needs: 1 patient actively assaultive, 4 patients on intermediate risk suicide (high potential for self-injury: requires close observations), 1 patient having hallucinations/delusions, 5 patients admitted within the last 48 hours, 3 patients constantly demanding staff time (e.g. requests, interruptions), 9 patients on every 15-30 minute supervision checks.

3. Adolescent Psychiatric Unit

4. An analysis of the Staffing Data collected on the second day of survey (1/18/17) and for the week of 1/11/17 through 1/17/17 revealed that the census ranged from 10 - 14 patients per day. There was 1 RN assigned with 3 MHT and a .5 LPN for 5 days, working from 11:00 a.m. to 7:00 p.m. on the day and evening shifts. This resulted in no consistent additional licensed staff available to provide assistance in cases of emergencies and for the RN's meals and breaks. Additionally, because of the RN workload, there was sporadic time available to provide ongoing interactions with patients.

5. A review of the Needs Assessment document revealed a high patient acuity that would require consistent, and ongoing oversight by an RN. The patient acuity on this unit required an RN to be available to provide active treatment interventions and clinical supervision of paraprofessional staff. The Needs Assessment document completed revealed a census of 15 patients with the following needs: 4 patients potentially assaultive (has occasionally demonstrated during hospitalization), 7 patients on low risk suicide (requires some protection against impulses), 8 patients on immediate risk suicidal (high potential for self-injury; requires close observation), 1 patient having hallucinations/delusions, 2 patients take medications reluctantly, 6 patients on assault precautions, 1 patient admitted within the last 48 hours, 8 patients constantly demand staff time (e.g. requests, interruptions), 1 patient on special monitoring due to eating disorder, 3 patients on self-abusive observation, 1 patient on 1:1 supervision, 14 patients under constant line of supervision, 15 patients on every 15-30 minute supervision checks.

C. Interviews

1. In an interview on 1/18/17 at 9:35 a.m., RN1 stated that there was not enough staff and she does not get relief for breaks and lunches. She also stated that, "There are agency nurses every day and they don't do the core duties. They get through their shift and the nurse that follows picks up the work. They (agency nurses) also refuse to do the intake admission."

2. In an interview on 1/18/17 at 10:00 a.m. with the MHT1, she stated, "We do need help. We are busy all the time."

3. In an interview on 1/18/17 at 10:25 a.m., Patient B2 stated that [s/he] was very upset that the "Agency Nurse" did not assess [his/her] pain scores for [his/her] medication. Patient B2 stated that another patient was sick because the "Agency Nurse" did not give the patient [his/her] medication.

4. In an interview on 1/18/17 at 3:50 p.m., the Director of Nursing reported that registered nurses provide education during medication administration. She agreed that this was an important nursing intervention and admitted that nurses did not sit with patients in individual sessions to provide medication education interventions included in MTPs.

Based on record review and interview the Social Work Director failed to

I. Provide psychosocial assessments that included a social evaluation reflecting specific community resources for utilization in discharge planning; conclusions that summarized psychosocial findings; and recommendations of the anticipated necessary steps for discharge to occur; and the anticipated social work roles in treatment and discharge planning for 8 of 8 sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). As a result, the treatment team did not have the necessary baseline social functioning needed for establishing treatment goals, interventions and discharge plans by social work staff. (Refer to B108).

II. Ensure that the Master Treatment Plans (MTPs) had adequately developed and individualized therapists treatment interventions, with a specific purpose and/or focus, based on the assessed needs of 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3 and B4). This deficiency results in treatment plans that failed to reflect a comprehensive and individualized social services approach to treatment. (Refer to B122).

III. Ensure that therapists' interventions listed on the treatment plan were documented in the electronic medical record to reflect the patients' response to interventions that included their level of participation and understanding, behaviors exhibited during interventions, and/or specific comments for 2 of 8 active sample patients (A2 and A4). This failure hindered the treatment team from determining the patient's response to social services 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 B124).

III. Ensure a system of monitoring of the quality of social work practice and provide supervision of staff who completed Psychosocial Assessments and performed discharge planning for 8 of 8 active sample patient (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically one staff members with a master's degree in social work (MSW) had not been assigned to provide oversight of the quality and appropriateness of social work practice. (Refer to B154).

Based on interview and record review, the facility did not assign one staff with a master's degree in social work (MSW) to fulfill the duties, functions, and responsibilities related to oversight of the quality and appropriateness of social work practice. This deficient practice results in no supervision and monitoring of the quality of the psychosocial assessments, discharge planning, and other social work practices by a MSW.

Findings include:

A. Document Review

The Curriculum Vitae for the Director of Social Services shows that the incumbent has a Master's Degree in Counseling Psychology and is a Licensed Professional Counselor.

B. Interview

During interview on 1/18/17 at 3:20 p.m. with the Director of Social Services, the oversight for the quality and appropriateness of social work practice was discussed. She reported that there was a MSW on each unit but one of them had not been assigned to provide oversight of the social services programming.

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

I. Employ a sufficient number of qualified Therapeutic Activities staff to provide and document active treatment for 8 of 8 active sample patients (A1, A2, A3, A4, B1, B2, B3, and B4). Specifically, the facility did not have an activity therapist to complete therapeutic activities assessments to ensure appropriate input into the formulation of the Individual Plan of Care/Individual Treatment Plan, as well offer therapeutic activities. In addition, there was no written description of the Therapeutic Activities Program. This failure results in patients not receiving a full complement of therapies, patients not being properly assessed regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities.

II. Provide documented evidence showing Mental Health Technicians (MHTs) competency to provide therapeutic activity groups. Specifically, MHTs provided most of the therapeutic activities titled "psychoeducational or rehabilitation" groups. MHTs did not have documented evidence that showed training to facilitate these groups, which they were assigned to lead. This failure results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings Include:

I. Therapeutic Activities Assessments and Interventions

A. Record Review

1. The facility policy: 300.8; Reviewed: 10/30/14, titled "Recreation Therapy Assessments," states: "All patients will have a recreation therapy assessment by a certified therapeutic recreation specialist (CTRS) within 72 hours of admission. The result of the assessment is used to establish the individual patient treatment needs."

2. There was no Therapeutic Activities Assessments located in the electronic medical records.

3. The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of plans in parentheses): A1 (1/17/17), A2 (1/10/17), A3 (1/13/17), A4 (1/11/17), B1 (1/15/17), B2 (1/11/17), B3 (1/15/17) and B4 (1/15/17). This review revealed that the section titled "Expressive Therapy" contained no intervention statements. The section titled "Milieu Mgmt [Management]/Rehab [Rehabilitation] contained the following identical or similarly worded stated: "MHT will facilitate four rehab groups per week by providing psychoeducational groups to improve ..."

B. Interview

1. In an interview on 1/18/17 at 2:00 p.m. with the Director of Social Work, who oversees Activity Therapy, the missing assessments were discussed. She stated that they do not have a Recreational Therapist, and that this policy should have been revised.

2. In a discussion on 1/19/17 at 10:45 a.m., the Director of Social Work, who oversees Activity, stated that she was unable to locate a written description of the facilities therapeutic activities program for the inpatient Adolescent and Adult Units.

II. Mental Health Technicians assigned to provide Therapeutic Activities

A. Record Review

1. The "Patient Daily Activity Schedule," listed the following groups reported by the facility to be Therapeutic Activities Groups: "Stress Management, Yoga, Pet Therapy, Coping Skills, Anger Management." All patients were expected to attend, irrespective of their problem and their individual needs.

2. The Master Treatment Plans for the active sample patients contained the following identical or similarly worded intervention assigned to Mental Health Technicians (MHTs): " MHT will facilitate four rehab [rehabilitation] groups per week by providing psychoeducational groups to improve coping skills to reduce anger/aggression and depression." The facility did not provide documentation regarding education/training and competency evaluations for MHTs to facilitate therapeutic activities groups.

3. During observation on 1/17/17 from 12:30p.m. to 1:00 p.m., MHT 3 conducted a group titled, "Stress Management." During observation on 1/18/17 from 2:00 p.m. to 3:00 p.m., MHT 2 conducted a group titled, "Anger Management." A review of personnel files for MHT 2 and MHT 3 revealed that the facility did not have documented evidence to substantiate education/training for them to conduct the groups to which they were assigned.

C. Interviews

1. In an interview on 1/18/17 at 3:10 p.m., the Staff and Training Coordinator, admitted that there was no documented evidence for MHTs showing their training and competence evaluation to provide therapeutic activities groups. He stated, "I am working on it."

2. In a discussion on 1/18/17 at approximately 4:00 p.m. the Director of Social Work who oversees Activity Therapy, stated that they had no recreational therapists. She stated, "We had to reduce staff due budget cuts." She also reported that Mental Health Technicians were assigned to do "rehabilitation" groups.