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Based on record review and interview, the hospital failed to ensure each patient had an individualized comprehensive treatment plan as evidenced by failing to ensure the patient's Treatment Plan included individualized, measurable goals and interventions for Activity's for 4 (#2, #3, #4, #5) of 5 sampled patients reviewed for Treatment Plans.

Findings:

Review of the policy titled "Treatment Plans", Document Number PC-501, dated July 10, 2012 revealed in part: To identify, evaluate, and update care and services appropriate to the individual's specific needs in order to promote therapeutic progress and provide treatment direction. B. Initial Treatment Plan. 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. This initial treatment plan is utilized to implement immediate treatment objectives. a) Therapeutic efforts begin when the initial treatment plan is developed. b) Problems are added to the problem list as they occur.

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Patient #2
Review of the medical record for patient #2 revealed that he was an 83 year old male with decreased cognitive abilities admitted to the hospital on 12/31/18 with a diagnosis of Dementia with behavioral disturbance. Further review of the record revealed Activity Assessment dated 01/02/19 which listed: Strengths: Verbal. Weaknesses: Negative use of leisure time skills, task performances, relating to authority figures, self-expression skills, self-control, coping skills, communication skills, social skills, frustration tolerance level, and stress management skills.

Review of the Treatment Plan dated 01/14/19 listed interventions: Cognitive skills activities to help improve thought process 45 min/day; 3x/wk. Objective: Patient will attend Activity Therapy group and accept redirection without verbal/physical aggression within 7 days.

Patient#3
Review of the medical record for patient #3 revealed that he was a 74-year-old male with short term and long term memory loss admitted to the hospital on 01/12/19 with a diagnosis of Major Depressive Disorder, recurrent episode severe, without mention of Psychotic behavior. Further review of the record revealed Activity assessment dated 01/14/19 which listed: Strengths: Verbal. Weaknesses: Self-worth, Self-satisfaction, Negative use of leisure time skills, Task performances, Self-expression skills, Self-control, Coping skills, Communication skills, Social skills, Frustration tolerance level, and Stress management skills.

Review of the Treatment Plan dated 01/16/19 listed intervention: Coping skills to help provide alternate means of dealing with life stressors 45min/day; 3x/wk.

Interview on 01/17/19 at 10:55 a.m. with patient #3 revealed that he enjoyed the activities here at the hospital and had no problems with the staff. Patient #3 further stated that he was limited in what he could do because he had a stroke and could not use his hands very well.

Patient #4
Review of the medical record for patient #4 revealed that she was a 54-year-old female with mild Mental Retardation admitted to the hospital on 01/03/19 with a diagnosis of Schizophrenia Disorder. Further review of the record revealed Activity Assessment dated 01/04/19 which listed: Strengths: Values relationship with family, and Verbal. Weaknesses: Self-worth, Self-satisfaction, Negative use of leisure time skills, Task performances, Relating to authority figures, Self-expression skills, Self-control, Coping skills, Communication skills, Social skills, Frustration tolerance level, and Stress management skills.

Review of the Treatment Plan dated 01/16/19 listed interventions: Coping skills activities to help provide alternate means of dealing with life stressors 45 min/day; 3x/wk. Objective: Patient will attend Activity Therapy group and show decrease in intrusive/impulsive behavior within 7 days.

Patient #5
Review of the medical record for patient #5 revealed that she was a 58-year-old female admitted to the hospital on 01/09/1912/31/18 with a diagnosis of Schizophrenia Disorder. Further review of the record revealed Activity Assessment dated 01/11/19 which listed: Strengths: Values relationship with family, and Verbal. Weaknesses: Negative use of leisure time skills, Relating to authority figures, Self-control, Coping skills, Frustration tolerance level, and Stress management skills.

Review of the Treatment Plan dated 01/16/19 listed interventions: Coping skills activities to help provide alternate means of dealing with life stressors 45 min/day; 3x/wk. Objective: Patient will attend AT group and show improvement with peer interaction within 7 days.

Interview on 01/17/19 at 10:45 a.m. with patient #5 stated that she had no problems and enjoyed the activity's each day. Patient #5 further stated that she had difficulty seeing and holding things in her hands but enjoyed playing games, movies and playing trivia.

Interview on 01/17/19 at 10:30 a.m. with S2DON confirmed the Treatment Plans were not individualized and had measurable goals and interventions for Activity's.

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan that included activities based on an activity assessment of the patients' likes and dislikes for 1 (#1) of 5 patient record reviewed for comprehensive treatment plans for a total sample of 5 patients.

Findings:

Review of the policy titled "Treatment Plans", Document Number PC-501, dated July 10, 2012 revealed in part: To identify, evaluate, and update care and services appropriate to the individual's specific needs in order to promote therapeutic progress and provide treatment direction. B. Initial Treatment Plan. 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. This initial treatment plan is utilized to implement immediate treatment objectives. a) Therapeutic efforts begin when the initial treatment plan is developed. b) Problems are added to the problem list as they occur.

Review of the hospital policy titled "Treatment Program Components", Document Number PC-101, dated July 10, 2012 revealed in part: E. Activities. Individual assessment and structured activities; Structured activities are conducted in a group setting and may include, but are not limited to, leisure activities such as playing games, doing simple arts and crafts projects and listening to music. This allows for socialization among the patients in our hospital.

Patient #1
Review of Patient #1's medical record revealed patient #1 was admitted to the hospital on 12/13/18 with a diagnosis of Dementia with behavioral disturbance. Further review revealed an Activity assessment dated 12/14/18 which listed: Strengths: Value relationship with family, and Verbal. Weaknesses: Negative use of leisure time skills, Task performances, Relating to authority figures, Self-expression skills, Self-control, Coping skills, Communication skills, Social skills, Frustration tolerance level, and Stress management skills. Further review revealed there was no activity goals and/or interventions included in the patients Treatment Plan.

Interview on 01/16/19 at 12:30 p.m. with S3LCSW confirmed patient #1's Treatment Plan did not include goals and/or interventions for Activity's.

Based on record reviews and interview, the hospital failed to ensure activity assessments were conducted by qualified therapists as evidenced by having no documented evidence S4AD possessed a degree in therapeutic recreation from a post-secondary institution or a degree in another field of study and had attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements or had a minimum of 10 years' experience providing therapeutic recreational services. S4AD completed and documented the activity assessments for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for activity assessments from a sample of 5 patients.

Findings:

Review of S3AD personnel file revealed a date of hire of 01/07/08. S4AD had a Bachelor's degree in Criminal Justice and a Minor in Business and Psychology. Further review revealed no documented evidence that she had attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements. Further review revealed no documented evidence that she had a minimum of 10 years' experience providing therapeutic recreational services or that she was employed as a therapeutic recreation specialist 2 per the Louisiana Civil Service requirements.



Review of the medical records for patients #1, #2, #3, #4 and #5 revealed their activity assessments were conducted by S4AD.

Interview on 01/17/19 at 9:00 a.m. with S7EH confirmed that S4AD did not meet the above listed requirements for Therapeutic Recreational Therapist.