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Based on facility policy and procedure, medical record review and staff interviews, the facility staff failed to ensure a behavioral health patient was able to participate in treatment by failing to ensure a cochlear implant device (a small electronic device that electrically stimulates the nerve for hearing) was functioning for 1 of 1 patient with a hearing deficit (Patient #13).

The findings include:

Review on 03/31/2022 of the hospital policy titled, "Patient Rights and Responsibilities" revised on 01/15/2021 revealed " ... Access to treatment ... will be impartial and free of discrimination from race, color, nationality, sex, gender identity, sexual orientation, disability, culture, economic background, educational background, religious background, or the source of payment for care ... 5. The patient has the right to receive information from his/her physician about his/her illness, course of treatment, outcome of care (including unanticipated outcomes), and his/her prospects of recovery in terms the patient can understand ...

Review on 03/31/2022 of the hospital's "Patient's Bill of Rights" revised 10/2013 revealed "As a Patient, you have the right: ... 3. To hear from your physician, in language you can reasonably be expected to understand, your diagnosis, the treatment prescribed for you, the prognosis of your illness and any instruction required for follow up care; also to review your medical records and to have the information explained or interpreted as necessary except when restricted by law ..."

Review on 03/29/2022 of the closed medical record for Patient #13 revealed 16-year-old female that presented to the facility on 11/23/2021 at 0950 for "Suicidal ideations." Review of the Nurse Triage Comprehensive Assessment Tool-Intake dated 11/23/2021 at 0950 revealed " ... Recent Medical History: Cochlear Implants ..." Review of the HISTORY AND PSYCHIATRIC EVALUATION signed by Medical Doctor (MD) #1 on 11/24/2021 at 1000 revealed " ... Medical History (Chronic/Acute Illness, Current Medical Tx (treatment), Recent Hospitalization): Cochlear Implants ... PSYCHIATRIC AND MEDICAL DIAGNOSES: ... hearing impaired ..." Review of the Social Worker/Therapist Group form dated 11/24/2021 at 0900 revealed Patient #13 attended group therapy and was "quiet in group but did appear to be actively listening to group discussion". Review revealed "Achievement of objective" was checked for "Limited engagement/understanding." Review of the Psychiatric Progress Note dated 11/26/2021 at 1106 revealed " Pt (patient ) has an interpreter (a person who translates from one language to another) today who signs to her and is able to have a better conversation ..." Review of the Physician Discharge Summary dated signed 11/29/2021 at 0400 revealed Psychiatric and Medical Diagnosis: ... hearing impaired ..." Review revealed Patient #13 was discharged home on 11/29/2021.

Telephone interview on 03/31/2022 at 1119 with Patient #13's legal guardian revealed, Patient #13 had bilateral (both sides) cochlear implants when she arrived at the hospital. Interview revealed Patient #13 cannot hear anything if the cochlear devices were not charged. Interview revealed Patient #13 could read lips, however everyone is wearing mask during COVID, and could communicate through sign language.

Interview on 03/30/2022 at 1202 with Registered Nurse (RN) #7 revealed she did not remember Patient #13. Interview revealed after RN #7 looked at the documentation in Patient #13's medical record, she was the admissions nurse when Patient #13 presented. Interview revealed Patient #13 had cochlear implant devices in her ears as that was how she could hear what was going on. Interview revealed RN #7 would have notified the Medical Doctor (MD) to get an order for Patient #13 to be able to keep the cochlear device. Interview revealed RN #7 could not find a note of the communication to the MD nor an order for Patient #13 to keep the cochlear devices.

Interview on 03/30/2022 at 1034 with Registered Nurse (RN) #6 revealed she remembered a patient with cochlear implants. Interview revealed RN #6 reviewed her documentation in the medical record and she did the initial nursing assessment for Patient #13. Interview revealed there was no documentation on the initial nursing assessment that Patient #13 had cochlear implants nor a hearing deficit. Interview revealed the cochlear implants and hearing deficit should have been documented on the initial nursing assessment. Interview revealed an order should have been obtained for Patient #13 to have the cochlear implant devices and for the staff to charge them.

Interview on 03/30/2022 at 1240 with RN #8 revealed she remembered there being two patients with cochlear implant devices on the unit. Interview revealed the chargers to the cochlear devices were in the medication room. Interview revealed the night shift nurse would have taken the devices at night and put them on the charger for the next day. Interview revealed the night shift nurse would have given the cochlear devices back to the patients prior to RN #8 coming on duty. Interview revealed RN #8 could not say if Patient #13's cochlear implant device was charged.

Interview on 03/30/2022 at 1316 with Medical Doctor (MD) #9 revealed he did not remember Patient #13. Interview revealed had he seen the cochlear implant devices he would have documented them on the assessment. Interview revealed MD #9 did not remember if Patient #13 could hear and communicate without the cochlear implant devices being charged.

Interview on 03/31/2022 at 1025 with Licensed Clinical Social Worker (LCSW) #10 revealed she remembered Patient #13. Interview revealed Patient #13 did not participate much in group. Interview revealed the patient appeared to be "actively listening." Interview revealed Patient #13 was making eye contact with the LCSW #10, she was nodding or shaking her head, and smiling/looking at peers. Interview revealed nodding and looking did not mean the patient understood or could hear what was being said. Interview revealed it was discussed in treatment team and determined Patient #13 did not need an interpreter. Interview revealed LCSW #10 remembered at one point during Patient #13's stay a sign language interpreter was sitting with the patient during one of the group therapy sessions. Interview revealed if a patient had an interpreter of any kind, LCSW #10 would document "via interpreter" on top of their group note. Interview revealed LCSW #10 could not find a note she had written identifying an interpreter was involved in any of the group sessions for Patient #13.

In summary, Patient #13 had bilateral cochlear implant devices on admission to the hospital. There was no documentation that the devices were charged or that Patient #13's hearing was assessed without the use of the cochlear implant devices. Patient #13 was not actively participating in group therapy. Patient #13 was not assessed to verify if the patient could hear or understood what was being said from the date of admission (11/23/2021) until it was documented by MD #9 on 11/26/2022 requesting the use of a sign language interpreter for the patient to be able to have better communication.

Based on observation, facility policy review, medical record review, grievance log review, and staff interview, the facility staff failed to acknowledge a patient's written complaint as a grievance and provide written responses for 3 of 6 patient grievances identified. (Patient # 3, 9, 11)

The findings included:

Observation on 03/29/2022 at 1133 during a unit tour revealed grievance contact information posted on the wall.

Review of the facility policy, Patient and Family Grievances/The Role of the Patient Advocate, last reviewed 02/2021, revealed, "... It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be... a grievance is defined as a 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care... PROCEDURE... 4. The staff member receiving a verbal or written grievance shall insure that the Patient Advocate or House Supervisor are notified... 5. The Patient Advocate... shall investigate and address the grievance within 24 hours of the time the grievance is received if possible... 7. The Patient Advocate responding to the grievance shall inform the patient or family the timeframe within which he/she shall expect follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient shall be notified of the need for an extended time frame and an agreement made as to when follow up will occur, but no later than 30 days... 12. Any grievance received after a patient/resident is no longer in the hospital's system shall be forwarded to the Patient Advocate....13. If a grievance is received from legal counsel or regulatory, it shall be forwarded directly to the CEO (Chief Executive Officer) or Risk Manager, who shall delegate investigation to the appropriate staff members. It shall also be forwarded to the Corporate Risk Management or Legal Department for appropriate action as necessary..."

1. Closed medical record review of Patient #3 revealed a 45-year-old female admitted to the facility on 10/26/2021 at 1935 with a chief complaint of Bipolar Disorder. Review of Nursing Progress Note dated 10/28/2021 at 0710 by RN #11 revealed, "At approx (approximately) 0530 pt. (patient) was in a verbal altercation with another male peer (pt). Staff escorted this pt to her room and asked her what was all that about. She stated that yesterday when she was using the restroom the male pt came in through the other door and bent over and stared at her. She told him to get his (expletive) out of her bathroom.' this staff asked her why she didn't let staff know yesterday and she stated 'because I didn't want to start a bunch of confusion.' Staff notified the Supervisor and the on-call physician and received an order to move the male pt. to another unit." Medical record review revealed a handwritten document from Patient #3 dated 10/28/2021 at 0635 that detailed the incident with a male patient entering her bathroom. Review of Patient #3 written document revealed, "... I would like this to be documented as my written grievance. Due to the fact that I was instructed not to leave a msg (message) on the grievance #(number)." Medical record review revealed Patient #3 was discharged home on 11/08/2021 at 1614 via her personal vehicle.

Review of the Grievance Log on 03/29/2022 failed to reveal any complaints or grievances related to Patient #3 from August 2021 through March 2022.

Interview on 03/30/2022 at 1207 with RN #11 revealed she provided nursing care for Patient #3 on 10/28/2021. Interview revealed Patient #3 had gotten into a verbal fight with another patient and it was discovered that a male patient had walked into her bathroom while she was on the toilet. Interview revealed after finding out about the incident, RN #11 notified the House Supervisor and on-call provider to get the patients moved to different units. Interview revealed RN #11 could not recall Patient #3 wanting to file a grievance.

Interview on 03/30/2022 at 1214 with RN #12 revealed he provided nursing care for Patient #3 on 10/28/2021 after unit transfer. Interview revealed RN#12 could not recall Patient #3 nor a written complaint/grievance.

Interview on 03/30/2022 at 1505 with the Patient Advocate revealed he had not received the written grievance letter from Patient #3. Interview revealed if the letter had been received, the grievance would have been logged and investigated. Interview revealed the facility staff did not acknowledge the written complaint from Patient #3 and follow the grievance policy by providing Patient #3 a written response.

Interview on 03/31/2022 at 1325 with the CNO revealed that staff were expected to report patient grievances to the Patient Advocate. Interview revealed staff received training on hire about grievances and should have forwarded the letter of Patient #3 to the Patient Advocate for investigation. Interview revealed the Patient Advocate would have followed the policy for grienvances, including written responses.


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2. Review of the medical record for Patient #9, on 03/30/2022, revealed the patient was admitted 02/05/2022 with schizoaffective disorder bipolar type (serious psychiatric illness). Review of the History and Psychiatric Evaluation, signed 02/06/2022 at 1130, revealed "...Has guardian. ..." Record review revealed Patient #9 was discharged to a homeless shelter on 02/18/2022.

Review on 03/31/2022 of a letter received from the facility and addressed to the Chief Executive Officer, dated 03/03/2022, revealed "...I write today with grave concern about the way a situation has been handled regarding a patient.....(Name of Patient #9)......has been declared incompetent by a Clerk of Court, and (name or organization) - this organization - is his legal guardian and has been since 2010....we are frustrated and angry about the way in which (Patient #9) was discharged from (Name of Hospital)....We would like to hear from your.... team in the coming days that our letter has been received and that we should not be concerned or nervous to have people we support in your care. ..."

Review of the grievance file did not reveal a response letter was sent to the guardianship organization.

Interview with CCO #5 (Chief Clinical Officer) on 03/31/2022 at 1520 revealed the letter came in March and was sent to Risk Management for review. Interview revealed the patient advocate was not looped in to this concern. Interview revealed the grievance policy indicated a response would be sent within seven days. Interview revealed it was confusing in regards to who was to get involved. Further interview revealed no response was sent within seven days.



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3. Review of the medical record of Patient #11 revealed a 60 year old male admitted on 09/20/2021 after allegedly setting fire to his house then emerging from the woods with a sword and showing delusional ideation (reduced ability to form a valid conclusion; paranoid). Patient #11 was discharged on 09/27/2021 to a family's home. Review of the complaint log of an entry dated 09/30/2021, 3 days after discharge, revealed the department received a phone call from the daughter. "Patient's daughter complained about patient's aftercare plan and lack of communication between staff and patient's family."

Interview on 03/29/2022 at 1525 with Patient Advocate revealed Patient #11's daughter called and had conversation regarding the discharge plan. Interview revealed a grievance was not written.

Interview on 03/31/2022 at 1245 with CCO #5 revealed he was aware of the daughter calling after Patient #11 was discharged. Interview revealed the daughter's complaint should have been elevated to a grievance and the policy was not followed. Interview revealed no written response to a grievance was provided.

Based on policy review, medical record review and staff interviews, the hospital staff failed to allow the patient's legal guardian to participate in the development of the treatment plan / discharge for 3 of 15 patients with a legal guardian (Patient #12, #9, #8).

The findings include:

Review of the policy titled "COORDINATION WITH FAMILIES/SUPPORT SYSTEMS" last revised January 2021 revealed "...Special Considerations for Minors/Adults with Guardians 1. Legal guardians of minors/adults will automatically be involved in the care of patients...3. Legal guardians will be involved in the development of the patient's discharge plan..."

Review of the policy titiled "Interdisciplinary Patient-Centered Care Planning, reviewed 01/2021, revealed "...The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan. A designated staff member is responsible for discussing the treatment plan with the patient and family/representative/guardian if they are not present at the treatment team meeting....If necessary to do the review with the family member/representative remotely, that will be noted on the form. ..."

1. Review of a closed medical record revealed Patient #12 was a 65-year-old male involuntarily commited to the hospital (Hospital A) on 11/29/2021 at 1929 due to being a danger to others. Medical record review revealed Patient #12 had a history of Schizophrenia and Parkinson's disease. Review of the "BEHAVIORAL HEALTH CONSULT NOTE" from the referring facility (Hospital B) revealed documentation Patient #12 had a legal guardian. Review revealed the name and telephone number for Patient #12's legal guardian was present on the consult note.

Review of the "COMPREHENSIVE ASSESSMENT TOOL-INTAKE" form dated 11/29/2021 at 1957 revealed documentation that Patient #12 did not have a legal guardian. Review of a "Social Services Progress Note" signed by a therapist (LCSW #13) on 12/08/2021 (the day after discharge) at 0945 revealed "...Therapist found out...that (Patient #12's) biological daughter may be his legal guardian. Therapist contacted (Patient #12's) daughter and inquired about her being (Patient #12's) legal guardian as well as to gather social history. (Patient #12's) daughter made social worker aware that she is (Patient #12's) legal guardian and could provide documentation that will support guardianship..."

Medical record review failed to reveal evidence the admissions staff accurately documented Patient #12's legal guardianship. Medical record review failed to reveal evidence Patient #12's legal guardian was involved in treatment planning. Medical record review revealed Patient #12 discharged on 12/07/2021.

An interview was requested with the admissions nurse (RN #16) who was unavailable for interview.

Interview on 03/31/2022 at 1005 with the Director of Admissions revealed the expectation was the admissions staff would accurately document a patient's legal guardian. Interview revealed the admissions staff should ask for legal guardianship while receiving report from the referring facility and should also confirm with the patient during the admissions process. Interview revealed the clinical staff must be aware of a patient's guardianship in order to communicate treatment and discharge plans with the legal guardian.

Interview on 03/30/2022 at 1410 with Patient #12's therapist (LCSW #13) revealed she was not aware that Patient #12 had a legal guardian until she completed the Psychosocial Assessment on 12/06/2021 (7 days after admission). Interview revealed at that time, Patient #12 was determined to be clinically stable and discharged the next day.

Interview on 03/31/2022 at 1050 with the Director of Clinical Services revealed there was no evidence in the medical record that Patient #12's legal guardian was involved in treatment planning while admitted to the hospital.



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2. Review of the medical record for Patient #9, on 03/30/2022, revealed the patient was admitted 02/05/2022 with schizoaffective disorder bipolar type (serious psychiatric illness). Review of the History and Psychiatric Evaluation, signed 02/06/2022 at 1130, revealed "...Has guardian. ..." Review of the Interdisciplinary Master Treatment Plan (MTP), revealed it was signed by the physician, nurse, therapist, and recreation therapist on 02/08/2022 at 1400. Review revealed Patient #9 signed the plan. Master Treatment Plan review revealed a line which included boxes to be checked beside the following statements: "Patient has a legal guardian", "Contributed to goals/plan", "Aware of plan content" and "Refused to sign". Form review revealed none of the boxes were checked. Further plan review revealed a box to the side of a statement "Phone review completed with legal guardian". Review revealed the box was not checked and a space to indicate the guardian's name was not filled in. Master Treatment Plan review revealed no indication the legal guardian was involved with the treatment plan. Further review did not reveal an update to the the Master Treatment Plan prior to discharge on 02/18/2022 (10 days later).

Review of a document called Aftercare Instructions and Crisis Plan Instructions, dated 02/17/2022 and signed by a therapist and Patient #9 at 1315 on 02/17/2022, revealed a scheduled discharge time of 1030 and stated the patient would be discharged by "cab" to the shelter on 02/18/2022. Further review of this document revealed a phone review was completed with the legal guardian 02/17/2022 at 1430.

Review of another document called "...A. Physician Discharge Summary...", dated 02/18/2022, revealed Patient #9 was being discharged to a shelter. Review revealed the document was signed 02/18/2022 at 0900 by a physician, at 0930 by a nurse, and also signed by the patient. Review of the document revealed a line to note that a "Phone review completed with legal guardian...". Review revealed the line was blank with no documentation to indicate the guardian was contacted the day of discharge. Review of a Discharge Medication Summary form for Patient #9, dated 02/18/2022, revealed five medications were e-prescribed to a pharmacy and revealed a nurse and the patient signed the form. Medical record review failed to reveal notification of the guardian on the day of discharge.

Request for interview with the therapist/social worker involved with Patient #9 revealed the requested therapist was no longer in the position and not available for interview.

Interview with the Director of Clinical Services (DCS), on 03/31/2022 at 1145 revealed Patient #9 had a guardian identified in the medical record but there were no legal guardianship papers (court papers) on the medical record for staff to verify a legal guardian. Interview revealed hospital staff should have requested confirmation papers of legal guardianship and documented the attempts to do so in the medical record.

Interview on 03/31/2022 at 1022 with RN #18, who discharged Patient #9, revealed the RN did not recall knowing the patient had a legal guardian but indicated it made sense the patient would have one. The RN stated if a patient has a legal guardian the nurse should call the guardian the day of discharge to verify plans and go over discharge instructions. Interview revealed RN #18 did not contact the legal guardian the day of discharge. Further interview revealed if the RN had known about the legal guardian, she would have contacted the guardian, gone over all the discharge instructions/paperwork including all the medications. Interview revealed if the guardian came to the hospital for the discharge the guardian would receive a copy of the discharge instructions. The RN stated she did not know how the guardian would receive documented instructions otherwise. Interview revealed the Master Treatment Plan should indicate a legal guardian if there is one. Further interview revealed nurses do not contact shelters prior to patients being discharged to a shelter.

3. Review of the medical record for Patient #8, on 03/30/2022, revealed Patient #8 was admitted to the hospital on 09/17/2022 under involuntary commitment after an overdose. Patient #8's diagnoses included bipolar disorder (serious mental health disorder). Review of a document that stated "Letters of Appointment Guardian of the Person" revealed Patient #8 had a legal guardian. Review revealed the legal guardian's name and phone number was hand written on the guardianship paperwork. Review revealed the hand written name matched the legal guardian name listed on the document.

Record review revealed the "Interdisciplinary Master Treatment Plan" was signed by the Treatment Team, including the Psychiatrist, Nurse, and Therapist on 09/29/21 (12 days after admission). Treatment Plan review revealed a line which included boxes to be checked beside the following statements: "Patient has a legal guardian", "Contributed to goals/plan", "Aware of plan content" and "Refused to sign". Form review revealed none of the boxes were checked. Further plan review revealed another box to the side of a statement which noted "Phone review completed with legal guardian". Review revealed the box was not checked and the space to indicate the guardian's name was not completed. Master Treatment Plan review revealed no indication the legal guardian was involved in the treatment plan.

Interview with the Director of Clinical Services, on 03/31/2022 at 1145, revealed Patient #8 had a legal guardian and the appropriate paperwork was in the medical record. Interview revealed the Interdisciplinary Master Treatment Plan was not completed timely and did not document the involvement with the guardian.

Based on policy review, medical record reviews and staff interview, the facility staff failed to ensure a Master Treatment Plan was completed within 72 hours of admission, or updated as required for 6 of 9 sampled patients. (Patients #2, #12, #14, #24, #8, #9 )

Findings include:

Review of the facility policy titled "INTERDISCIPLINARY PATIENT-CENTERED CARE PLANNING" reviewed January 2021 revealed "...Procedure: Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ..."...The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days after the completion of the Master Treatment Plan. ..."

1. Review of a closed medical record on 03/29/2022 revealed Patient #2 was a 19-year-old female admitted to the hospital on 02/25/2022 at 1136 with Schizoaffective Disorder and Bipolar Disorder. Medical record review revealed Patient #2 was Involuntary Commited due to symptoms of Psychosis (auditory hallucinations). Review of the medical record revealed a Master Treatment Plan dated 03/03/2022 (144 hours (6 days) after admission). Medical record review revealed Patient #2 was discharged home 03/04/2022 at 1012.

Interview on 03/31/2022 at 1145 with LCSW #1 (Licensed Clinical Social Worker) revealed the Interdisciplinary Master Treatment Sheet should be completed during the Master Treatment Plan meeting within 72 hours (3 days) of admission to the facility.

Interview on 03/31/222 at 1516 with LCMHC #2 (Licensed Clinical Mental Health Counselor) revealed the patient's Master Treatment Plan should be complete within 72 hours (3 days) of admission to the facility. Interview revealed the clinical staff were responsible for creating the Master Treatment Plan and should be signed by the provider, the nurse and the therapist. Interview revealed LCSW #1 did not follow the facility's treatment plan policy.



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2. Review of a closed medical record revealed Patient #12 was a 65-year-old male involuntarily commited to the hospital on 11/29/2021 due to being a danger to others. Medical record review revealed Patient #12 had a history of Schizophrenia and Parkinson's disease. Review of Patient #12's medical record failed to reveal evidence of a Master Treatment Plan. Medical record review revealed Patient #12 discharged from the hospital on 12/07/2021 (8 days after admission).

Interview on 03/30/2022 at 1410 with the clinical therapist (LCSW #13) revealed the Master Treatment Plan must be completed within 72 hours of the patient's admission to the hospital. LCSW #13 was unable to located Patient #12's Master Treatment Plan during the interview. Interview revealed LCSW #13 could not recall if a Master Treatment Plan was created for Patient #12.

Interview on 03/31/2022 at 1050 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be completed within 72 hours of admission. Interview revealed Patient #12's treatment plan was out of compliance.

3. Review of a closed medical record revealed Patient #14 was a 19-year-old male involuntarily committed to the hospital on 11/04/2021 with psychosis. Medical record review revealed Patient #14 had a history of Schizophrenia. Medical record review revealed Patient #14's Master Treatment Plan was dated 11/10/2021 (6 days after admission). Medical record review revealed Patient #14 discharged from the hospital on 11/15/2021.

Interview on 03/31/2022 at 1050 with the Director of Clinical Services revealed the patient's Master Treatment Plan should be completed within 72 hours of admission. Interview revealed Patient #14's treatment plan was out of compliance.



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4. Review of a closed medical record on 03/31/2022 revealed Patient #24 was a 18-year-old male admitted to the hospital on 02/25/2022 at 1917 with increased aggressive behaviors towards self and others. Review of the medical record revealed a Master Treatment Plan dated 03/02/2022 (120 hours-5 days after admission). Medical record review revealed Patient #24 was discharged home 03/05/2022.

Interview on 03/31/2022 at 1056 with the Director of Clinical Services confirmed Patient #24's Master Treatment Plan was not completed in the expected 72-hour from admission time frame.



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5. Medical record review, on 03/30/2022, revealed Patient #8 was admitted to the hospital on 09/17/2022 under involutary commitment after an overdose. Patient #8's diagnoses included bipolar disorder (serious mental health disorder). Review of a document that stated "Letters of Appointment Guardian of the Person" revealed Patient #8 had a legal guardian. Review revealed the "Interdisciplinary Master Treatment Plan was signed by the Treatment Team, including the Psychiatrist, Nurse, and Therapist on 09/29/21 (12 days after admission). Further review revealed the Master Treatment Plan did not indicate Patient #8 had a legal guardian and did not indicate the legal guardian was notified by phone or contributed to the goals or plan. Review failed to reveal the Interdisciplinary Master Treatment Plan was completed as required.

Interview with RN #21 on 03/31/2022 at 1345 revealed the Master Treatment Plan for Patient #8 was late. Interview revealed it should have been completed within 3 days.

6. Review of the medical record for Patient #9, on 03/30/2022, revealed the patient was admitted 02/05/2022 with schizoaffective disorder bipolar type (serious psychiatric illness). Review of the History and Psychiatric Evaluation, signed 02/06/2022 at 1130, revealed "...Has guardian. ..." Review of the Interdisciplinary Master Treatment Plan (MTP), revealed it was signed by the physician, nurse, therapist, and recreation therapist on 02/08/2022 at 1400. Interdisciplinary Master Treatment Plan review did not reveal any updates to the treatment plan. MTP. Review revealed Patient #9 was discharged on 2/18/2022, 10 days after the initial treatment plan was signed. Review failed to reveal the MTP was updated in 7 days as required.

Request for interview with the therapist/social worker involved with Patient #9 revealed the requested therapist was no longer in the position and not available for interview.

Interview with the Director of Clinical Services, on 03/31/2022 at 1145 revealed the Master Treatment Plan should be updated every 7 days.

NC00183701; NC00187008; NC00181892; NC00183917; NC00184057; NC00181809; NC00186667; NC00183511; NC00182884; NC00187305; NC00185484; NC00182745; NC00183343; NC00187033; NC00181091; NC00181756