HospitalInspections.org

Based on document review and interview, the Governing Board failed to maintain documentation of periodic consultation with the Chief Medical Officer (CMO) or designee responsible for the leadership of the Medical Staff for 4 of 4 quarters in 2017 and 2018 (3rd + 4th quarter 2017 and 1st + 2nd quarter 2018).

Findings include:

1. On 6-25-18 at 1130 hours, the Executive Director of Quality Improvement and Compliance, staff A4 and the Chief Operating Officer, staff A6 were requested to provide documentation indicating periodic consultation between the Board of Directors and the CMO, staff MD11 or designee and none was provided prior to exit.

2. Review of the Governing Body Bylaws (reviewed 9-17) indicated the following: "Article IV. Committees Section 2... The Administrative Committee shall... Act in an advisory capacity to the management of the Corporation... Section 3... The Services/Planning/Evaluation Committee shall... Advise the Board of Directors in respect to any matters relating to the Corporation's development and provision of direct and/or indirect behavioral health care services to the community (including but not limited to alcohol and drug, developmental disabilities, mental illness, intervention/prevention and education services)."

3. Review of the 7-25-17, 8-22-17, 9-26-17, 11-28-17, 1-23-18, 2-27-18, 3-27-18, 4-24-18, 5-22-18 and 6-26-18 Board Administrative Committee minutes and Services/Planning/Evaluation Committee minutes indicated Physician MD11 was notified of the Board committee meetings and no committee meeting documentation or Board of Directors meeting minutes (including the 10-24-17 Annual Board of Directors meeting) indicated staff MD11 attended any meetings.

4. On 6-27-18 at 1420 hours, staff A4 confirmed the Board meeting minutes lacked documentation indicating the CMO attended any meetings and confirmed no other documentation of periodic consultations between the Board and the CMO was available.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided, for 10 of 148 contracted services (dietitian services, inpatient meals (dietary services), document destruction, laundry service, medical laboratory testing, inpatient pharmacy services, outpatient pharmacy and pharmacist services, radiology and waste disposal).

Findings include:

1. Review of a list of contracted services received from the Executive Director of Quality Improvement and Compliance, staff A4 lacked documentation indicating a provider for a dietitian and dietary services, document destruction, laundry, medical laboratory testing, inpatient pharmacy and pharmacist services, outpatient pharmacy services, radiology and waste disposal services.

2. Review of facility administrative documentation indicated the nearby acute care facility provided dietitian and dietary services, laundry services, inpatient pharmacy services, and radiology services and additional facility administrative documentation indicated document destruction was provided by CS1, medical laboratory testing by CS2, outpatient pharmacy and pharmacist services by CS3, and waste disposal services by CS4.

3. On 6-26-18 at 1350 hours, staff A4 confirmed the list failed to indicate a provider for the identified services and no other documentation was available.

Based on document review and interview, the quality assessment and performance improvement (QAPI) program failed to ensure documentation of periodic quality indicator monitoring was maintained for 2 of 14 services selected for review (dietary & pharmacy).

Findings include:

1. Review of the Corporate Compliance Plan (approved 9-17) provided in response to a request for a copy of the facility's QAPI plan/program indicated the following: "II.C.2 Compliance, Quality, Risk, and Improvement Committee... In partnership with all departments, this committee is charged with applying structure to the measurement and evaluation process for the ongoing performance, improvement, and compliance with regulatory bodies. This committee is comprised of an interdisciplinary team."

2. Review of the 8-8-17, 11-10-17, 3-14-18 and 5-22-18 CQRI (Compliance, Quality, Risk, and Improvement) meeting minutes lacked reporting data for the contracted dietary and pharmacy service providers.

3. On 6-27-18 at 1505 hours, the Executive Director of Quality Improvement and Compliance, staff A4 confirmed the CQRI minutes lacked documentation of periodic quality indicator monitoring for the dietary and pharmacy services.

Based on document review and interview, the Governing Body failed to follow its Bylaws and periodically review its quality assessment and performance improvement (QAPI) program documentation including inpatient services at least annually for 4 of 4 quarters in 2017 and 2018 (3rd + 4th quarter 2017 and 1st + 2nd quarter 2018).

Findings include:

1. Review of the Governing Body Bylaws (reviewed 9-17) indicated the following: "Article IV. Committees Section 4... The Professional Affairs Committee shall... periodically review the center's quality assessment initiatives including processes that are designed to improve patient, staff, and visitor safety, infection control, medication use, utilization management or other initiatives that are targeted toward improving patient care... these initiatives include reviewing the activities of the center's standing quality committees on an annual basis."

2. Review of the 7-25-17, 8-22-17, 9-26-17, 10-24-17, 11-28-17, 1-23-18, 2-27-18, 3-27-18, 4-24-18, 5-22-18 and 6-26-18 Board of Directors meeting minutes including the Professional Affairs Committee (PAC) minutes lacked documentation indicating any inpatient services, or Compliance, Quality, Risk, and Improvement Committee minutes, or Quality Management Committee minutes were presented or summarily reviewed.

3. On 6-27-18 at 1405 hours, the Executive Director of Quality Improvement and Compliance, staff A4 confirmed the indicated Board of Directors meeting minutes including its Board Committee meeting minutes lacked documentation of inpatient QAPI reporting activity and confirmed no other documentation was available.

Based on document review and interview, the Medical Staff failed to follow its Bylaws and maintain documentation of medical staff reappointments for 2 of 3 credential files reviewed (Physicians MD11 & MD12).

Findings include:

1. Review of the Medical Staff Bylaws (revised 2-16) indicated the following: "Article IV. A Medical Staff Executive Committee (MSEC)... 2(a) The MSEC is responsible for reviewing and making any necessary recommendations to the Board and CEO [Chief Executive Officer] with regard to... Applicants for Medical Staff appointment... Article V. C Provisions Common to all Meetings... 4(b) Reports and Recommendations, including credentialing and privileging... shall routinely flow from the MSEC to the Board through either the Professional Affairs Committee [PAC] of the Board or the CEO."

2. Review of the 7-19-17, 8-16-17, 10-18-17, 12-20-17, 2-21-18, 3-21-18, 4-18-18 and 5-16-18 Medical Staff/MSEC meeting minutes lacked documentation indicating the names of any Medical Staff candidates that were approved for appointment/reappointment including the Chief Medical Officer (CMO), staff MD11 and the Physician, staff MD12.

3. Review of the 7-25-17, 8-22-17, 9-26-17, (no 10-24-17 PAC meeting), 11-28-17, 1-23-18, 2-27-18, (no 3-27-18 PAC meeting), 4-24-18 and 5-22-18 PAC minutes lacked documentation indicating staff MD11 or MD12 were reappointed in 2017 or 2018 to the Medical Staff by the Board committee.

4. Review of the credential files for staff MD11 and MD12 indicated both Medical Staff members were most recently reappointed on 3-22-16 with an expiration date of 3-21-18 and lacked documentation indicating either staff had been reappointed in 2018.

5. On 6-27-18 at 1540 hours and 1550 hours, the Executive Director of Quality Improvement and Compliance, staff A4 and the Human Resource Manager, staff A10 confirmed the credential files for staff MD11 and MD12 lacked documentation indicating either physician had been recently reappointed to the Medical Staff and confirmed no other documentation was available.

Based on document review and interview, the nurse executive failed to ensure staff administered medications as ordered by a practitioner in 1 of 20 medical records (MR's) reviewed.

Findings include:

1. Policy/procedure, Policy No. SOC 5.2.0, Physician Orders, transcribing, revised/reviewed 4/17, indicated: "The nurse is accountable and responsible for documenting and administration of all physician orders".

2. Review of N1's Medication Administration Record (MAR) indicated: "1/9/18: Haldol 5 mg by mouth (PO)/intramuscular injection (IM) every 6 hours as needed (PRN) for agitation".

3. Review of N1's MAR lacked documentation of administration route of Haldol 5 mg on 1/9/18 at 1330 hours, 1/21/18 at 1615 hours, 1/22/18 at 1530 hours and 1/23/18 at 1335 hours.

4. Review of N1's MAR indicated: "1/9/18: Ativan 2 mg PO/IM every 6 hours PRN anxiety".

5. Review of N1's MAR lacked documentation of administration route of Ativan 2 mg on 1/17/18 at 1345 hours, 1/19/18 at 0830 and 1430 hours, and 1/21/18 at 1615 hours.

6. On 6/26/18 at approximately 1300 hours, staff P1 (Executive Director) was interviewed and confirmed N1's MAR lacked documentation of administration route of Haldol 5 mg on 1/9/18 at 1330 hours, 1/21/18 at 1615 hours, 1/22/18 at 1530 hours and 1/23/18 at 1335 hours and Ativan 2 mg on 1/17/18 at 1345 hours, 1/19/18 at 0830 and 1430 hours, and 1/21/18 at 1615 hours. Staff P1 confirmed staff should document medication routes of administration as ordered by physicians.

Based on document review and interview, the facility failed to ensure all drug administration errors and adverse medication reactions would be immediately reported to the attending Physician for one facility.

Findings include:

1. Review of the policy/procedures titled Adverse Drug Reaction Monitoring/Reporting (reviewed 5-17) and Safety Internal Event and Incident Reporting (reviewed 5-17) lacked documentation indicating a requirement to immediately report all drug administration errors and adverse medication reactions to the attending Physician.

2. On 6-27-18 at 1520 hours, the Executive Director of Quality Improvement and Compliance, staff A4 confirmed the policy/procedures lacked the indicated requirement.

Based upon document review and interview, the facility failed to follow its utilization review (UR) plan and ensure at least two doctors of medicine or osteopathy participated in the review of services at least quarterly (see tag A654 Utilization Review Committee) and ensure a periodic review of medical necessity was conducted for all extended stay cases within a timeframe specified in the UR plan (see tag A657 Extended Stay Review).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Utilization Review was conducted in a manner to promote the most efficient use of the available facilities and services.

Based on document review and interview, the facility failed to follow its Utilization Review (UR) plan and ensure at least two doctors of medicine or osteopathy participated in the review of services at least quarterly for 4 of 4 quarters in 2017 and 2018 (3rd + 4th quarter 2017 and 1st + 2nd quarter 2018).

Findings include:

1. Review of the policy/procedure Utilization Management Plan Inpatient Unit Fiscal Year 2017 (no approval date) indicated the following: "Inpatient utilization review activities will be completed through the Utilization Review Committee. The committee will meet quarterly to review inpatient stays... The committee membership will include two physicians per CMS regulations..."

2. Review of the 9-19-17 UM committee minutes failed to indicate two (2) of 2 physicians attended and participated in the UR meeting activity for 2 of 4 quarters in 2017 and review of the 6-21-18 UR committee minutes failed to indicate one (1) of 2 physicians attended and participated in the meeting activity for 2 of 4 quarters in 2018.

3. On 6-26-14 at 1330 hours, the Executive Director of Quality Improvement and Compliance, staff A4 confirmed the 9-19-17 and 6-21-18 UR committee meeting minutes were the only minutes available for 2017 and 2018, the two (2) UR committee meeting minutes lacked documentation indicating at least two (2) physicians attended each meeting, and the UR committee failed to conduct quarterly meetings in accordance with the plan.

Based on document review and interview, the Utilization Review (UR) program failed to establish and ensure a periodic review of each inpatient receiving hospital services of extended duration was performed within seven (7) days of the date specified in the UR plan for 4 of 4 quarters in 2017 and 2018 (3rd + 4th quarter 2017 and 1st + 2nd quarter 2018).

Findings include:

1. Review of the policy/procedure Utilization Management Plan Inpatient Unit Fiscal Year 2017 (no approval date) indicated the following: "The committee will meet quarterly to review inpatient stays and related quality indicators... [and]... an emphasis on evaluating necessity of short and long stays will be documented..." and lacked documentation indicating a committee requirement to conduct a periodic review of inpatient records including each inpatient receiving hospital services during a continuous period of extended duration within seven (7) days of an interval specified by the UR plan.

2. Review of the 9-19-17 and 6-21-18 UM committee minutes provided for review lacked documentation indicating quarterly UR committee meetings were held or indicating periodic reviews of inpatient admissions including extended inpatient stays were conducted in accordance with the UR plan.

3. On 6-26-14 at 1330 hours, the Executive Director of Quality Improvement and Compliance, staff A4 confirmed the UR plan failed to indicate a requirement to conduct a review of inpatient stays including continuous stays of extended duration at specified intervals and confirmed the UR committee minutes lacked documentation indicating quarterly meetings were held or indicating periodic reviews of inpatient admissions including extended inpatient stays were conducted at specified intervals and no other documentation was available.

A Recertification Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41.

Survey Date: 06/26/18

Facility Number: 005174

At this survey, Hamilton Center Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This two story facility was determined to be of Type II (222) construction and was partially sprinklered. All client sleeping rooms were located on the second floor. The facility has a fire alarm system with hard wired smoke detectors in the corridors and spaces open to the corridors. The facility has a capacity of 16 and had a census of 15 at the time of this survey. The entire second floor of the facility was surveyed because there was no 2- hour separation between the health care unit and the business occupancy also located on the second floor.

The second floor Supply Room was the only area of the facility with sprinkler coverage.

Based on document review, observation and interview, the facility failed to ensure 5 of over 45 door within the facility were provided with door latches that required only one operation to open (see tag K200), the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period (see tag K346), the facility failed to provide a written policy containing procedures to be followed for the protection of 15 of 15 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period (see tag K354), the facility failed to ensure 4 of 18 sets of patient room doors to the corridor would close and latch into the door frame (see tag K363), the facility failed to exercise the generator annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems (see tag K918), the hospital failed to maintain and provide its environment of care in a manner to protect and ensure the safety of at-risk patients for 16 of 16 inpatient rooms at the facility (see tag A722) and for one defibrillator equipment (see tag A724).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure a safe environment was maintained to provide quality health care for patients.

Based on record review and interview, the facility failed to exercise the generator annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating.
Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

Findings include:

Based on record review on 06/26/18 at 10:19 a.m. of the generator load testing documentation with the Chief Operating Officer, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Chief Operating Officer acknowledged the generator ran under load on a weekly basis but he could not provide documentation to show the generator could achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator may have occurred within the past year, but the documentation could not be provided at the time of this survey. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure 5 of over 45 door within the facility were provided with door latches that required only one operation to open. LSC 19.2.2.1 states doors complying with 7.2.1 shall be permitted. 7.2.1.5.10.2 requires the releasing mechanism shall open the door leaf with not more than one releasing operation. This deficient practice could affect as many as 5 patients, 2 staff and visitors within the facility, the facility failed to ensure 4 of 18 sets of patient room doors to the corridor would close and latch into the door frame. This deficient practice could affect approximately 4 patients, as well as staff and visitors.

Findings include:

1.Based on observation on 06/26/18 between 11:18 a.m. and 12:55 p.m. with the Chief Operating Officer, the following was noted:
1) The door mechanism to the second floor Records Clerks office had two operating mechanisms on it, a door handle and a deadbolt lock.
2) The door mechanism to the second floor Recreation room had two operating mechanisms on it, a door handle and a deadbolt lock.
3) The door mechanism to the second floor Conference room had two operating mechanisms on it, a door handle and a deadbolt lock.
4) The door mechanism to the second floor Group room had two operating mechanisms on it, a door handle and a deadbolt lock.
5) The door mechanism to the second floor Inpatient unit Clinical staff office had two operating mechanisms on it, a door handle and a deadbolt lock.

2. Based on observation on 06/26/18 between 10:18 a.m. and 12:55 p.m. with the Chief Operating Officer, the following was noted:
1) Patient room # 278 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
2) Patient room # 280 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
3) Patient room # 282 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
4) Patient room # 284 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
Based on interview at the time of observations, Chief Operating Officer acknowledged all the above listed doors having only a dead bolt as the doors only latching mechanism. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants, the facility failed to provide a written policy containing procedures to be followed for the protection of 15 of 15 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants in the facility.

Findings include:

1. Based on record review on 06/26/18 between 9:20 a.m. and 11:16 a.m. with the Chief Operating Officer, the facility had a fire watch plan entitled "Fire Watch", but it was incomplete. The plan states " ...fire watch rounds will be continuous and will be done at intervals by an individual with no other job duties." It does not however state that the person conducting the fire watch shall be a trained person. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged the fire watch documentation provided did not state anything about the individual doing the fire watch as having to be a trained individual. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

2. Based on observation on 06/26/18 between 9:20 a.m. and 11:16 a.m. with the Chief Operating Officer, the facility had a fire watch plan entitled "Fire Watch", but it was incomplete. The plan states " ...fire watch rounds will be continuous and will be done at intervals by an individual with no other job duties." It does not however state that the person conducting the fire watch shall be a trained person. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged the fire watch documentation provided did not state anything about the individual doing the fire watch had to be a trained individual, or have proper training. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on document review, observation and interview, the hospital failed to maintain its environment of care in a manner to ensure the safety of patients at risk for self-harm for 16 of 16 inpatient rooms at the facility.

Findings include:

1. Review of the policy/procedure Safety Plan (reviewed 11-16) indicated the following: "The Environment of Care Survey team assesses facilities during environmental tours and reports their findings to the Safety and Security Committee."

2. Review of the 7-18-17, 8-15-17, 9-19-17, 10-17-17, 1-16-18, 2-20-18, 3-20-18, 4-24-18 and 6-19-18 Safety Committee minutes lacked documentation indicating the inpatient unit was assessed for features that allowed for securing clothing, textiles, or other material to fixtures and/or equipment to enable self-asphyxiation by a patient at risk for self-harm.

3. During a tour on 6-27-18 at 1135 hours, in the company of the Director of Operations and Safety Officer, staff A3, and the Chief Operating Officer, staff A6, the following hazardous condition was observed on the inpatient unit in the bathrooms of patient rooms 282 and 284: an exposed metal water supply pipe extending out 6" from the wall approximately 36" above the floor connected horizontally with a 90 degree elbow and short pipe extension to a metal flush mechanism and vertical exposed metal pipe leading to a floor-mounted porcelain commode.

4. On 6-27-18 at 1140 hours, staff A3 and staff A6 confirmed each one of the 16 inpatient bathroom commodes were constructed using exposed metal piping connected to a flush mechanism and confirmed the exposed metal piping represented a critical safety hazard by creating a secure attachment point for attempting suicide by ligature resulting in death by asphyxiation.

Based on document review, observation and interview, the facility failed to maintain its emergency equipment in accordance with the manufacturer's recommendations for 1 equipment.

Findings include:

1. Review of the LifePak 1000 Operators Guide (published 5-16) Section 5-4 Battery Maintenance indicated the following: "Note: Always carry a spare, fully-charged battery" and review of Appendix E: LifePak 1000 Defibrillator User's Checklist indicated the following: "3. Check spare battery. Ensure spare, fully charged battery is available."

2. During a tour of the inpatient unit on 6-27-18 at 1110 hours, in the company of the Director of Operations and Safety Officer, staff A3, the Executive Director of Quality Improvement and Compliance, staff A4, and the Executive Director of Medical Services, staff A5, the following condition was identified: a LifePak 1000 AED (Automatic External Defibrillator) was observed in the nursing station without a spare battery in the general vicinity.

3. On 6-27-18 at 1110 hours, staff A3 and A5 confirmed that a spare battery was not available for use with the AED in accordance with the manufacturer's recommendations.

Based on document review, observation and interview, the infection control committee failed to ensure compliance for personnel screening of tuberculosis (TB) upon hire for 13 (P1, P2, P3, P6, P7, P8, P9, P10, P11, P12, P13, P14, and P15) of 15 personnel files reviewed and failed to ensure proper storage of clean supplies on 1 (inpatient unit) of 1 unit toured.

Findings include:

1. Policy/procedure, EC 05.01.05.00, Exposure Control Plan Employee Counseling, TB Screening and Evaluation, revised/reapproved 4/17 indicated on page 3: "Two-Step Testing: 1. Used for all new hires with regular assignment in 24-hour service areas at Hamilton Center, Inc, i.e. residential services and inpatient services".

2. Review of personnel files confirmed P1, P2, P3, P6, P7, P8, P9, P10, P11, P12, P13, P14, and P15's personnel files lacked documentation of two-step screening for TB upon hire.

3. Staff P15 (Infection Control Nurse) was interviewed on 6/25/18 at approximately 1400 hours and confirmed the above-mentioned personnel files lacked documentation of two-step screening for TB upon hire.

4. While on tour of the inpatient unit on 6/26/18 at approximately 1515 hours accompanied by staff P16 and P17, a duffel bag was observed on the floor of the soiled utility room.

5. Staff P17 (Patient Care Specialist) was interviewed on 6/26/18 at approximately 1530 hours and confirmed the duffel bag observed was a clean supply item containing patient restraints. Staff P17 confirmed he/she had placed the duffel bag in the soiled utility room. Staff P17 confirmed he/she should have placed the duffel bag in the clean supply room to avoid contamination.

Based on medical record review, policy review and staff interview the facility failed to provide Psychosocial Assessments on eight (8) out of eight (8) active sample patients (M1, M2, M3, M4, C1, C2, C3, C4) that included a summary of the findings, conclusions and recommendations that described anticipated social work role in treatment and discharge planning. This failure resulted in the treatment team receiving incomplete psychosocial content upon which to base the development of the treatment plan and discharge planning.

Findings Include

A. Record Review:

Patient M1's Biopsychosocial Assessment dated 6/06/18 did not include a summary of the findings, conclusions and recommendations. The discharge planning listed "Once client has stabilized he/she will be discharged with outpatient follow-up services".

Patient M2's Biopsychosocial Assessment dated 6/08/2018 did not include a summary of the findings, conclusions and recommendations. The discharge planning listed "Once client has stabilized he/she will be discharged with outpatient follow-up services."

Patient M3's Biopsychosocial Assessment dated 6/07/18 did not include a summary of the findings, conclusions and recommendations. The discharge planning listed "Once client has stabilized and is no longer a danger to himself/herself, he/she will be discharged with the appropriate outpatient services."

Patient M4's Biopsychosocial Assessment dated 6/23/18 did not include a summary of the findings, conclusions and recommendations. The discharge planning listed "Once client has stabilized and is no longer a danger to himself/herself, he/she will be discharged with outpatient follow-up services."

Patient C1' s Biopsychical Assessment dated 5/17/18 did not include a summary of the findings, conclusions and recommendations. The dis

Based on medical record review, policy review and staff interview, the facility failed to assess and estimate the intellectual and memory functioning in a sufficiently descriptive manner to establish baseline parameters for eight (8) out of eight (8) - (M1, M2, M3, M4, C1, C2, C3, C4) active sample patients, in the "IP (Inpatient) Admission Note", title for the hospital psychiatric evaluation. This failure compromises the data base from which diagnoses are determined and from which treatment interventions may be measured.

Findings Include:

A. Record Review

Patient M1, admitted 6/04/18, IP Admission Note dated 6/05/18, did not include an assessment of patient's memory and intellectual functioning.

Patient M2, admitted 6/06/18, IP Admission Note dated 6/07/18, did not include an assessment of patient's memory and intellectual functioning.

Patient M3, admitted 6/05/18, IP Admission Note dated 6/06/18, did not include an assessment of patient's memory and intellectual functioning. Montreal Cognitive Assessment (MOCA) was performed but it did not include a date on the assessment

Patient M4, admitted 6/21/18, IP Admission Note dated 6/25/18, did not include an assessment of patient's memory and intellectual functioning.

Patient C1, admitted 5/15/18, IP Admission Note dated 5/17/18, did not include an assessment of the patient's memory and intellectual functioning.

Patient C2, admitted 6/19/18, IP Admission Note dated 6/20/18, did not include an assessment of patient's memory and intellectual functioning.

Patient C3, admitted 6/18/18, IP Admission Note dated 6/21/18, did not include an assessment of patient's memory and intellectual functioning.

Patient C4, admitted 6/06/18, IP Admission Note dated 6/08/18, did not include an assessment of patien

Based on medical record review and staff interviews the facility failed to provide psychiatric evaluations that included an assessment of patient assets/strengths in descriptive fashion for seven (7) out of eight (8) active sample patients (M1, M2, M3, M4, C1, C3, C4). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in treatment.

Findings Include:

A. Record Review

Patient M1's psychiatric evaluation dated 6/05/18 had listed" Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Patient M2's psychiatric evaluation dated 6/07/18 had listed "Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Patient M3' s psychiatric evaluation dated 6/06/18 listed "Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Patient M4's psychiatric evaluation dated 6/25/18 listed" Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Patient C1's psychiatric evaluation dated 5/17/18 listed "Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Patient C3's psychiatric evaluation dated 6/21/18 listed Access to health care" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

Based on medical record review, policy review and staff interview the facility failed to ensure that treatment plans were based on an inventory of the patient's strengths in eight (8) out eight (8) active sample patients (M1, M2, M3, M4, C1, C2, C3, C4). This failure dismisses the effectiveness of treatment interventions by not engaging the patient through use of their strengths in developing interventions to accomplish treatment goals.

Findings

A. Record Review

Patient M1's treatment plan dated 6/06/18 listed as strengths "Willingness to advocate for self" and "Access to care."

Patient M2's treatment plan dated 6/08/18 did not list any strengths.

Patient M3's treatment plan dated 6/08/18 did not list any strengths.

Patient M4's treatment plan dated 6/23/18 did not list any strengths.

Patient C1's treatment plan dated 5/22/18 did not list any strengths

Patient C2's treatment plan dated 6/25/18 listed Volunteering, 2-Identified, Job History, 2-Identified, Spiritual/Religious, 3 Identified, Community Connection, 2 Identified, Natural Supports-unpaid individuals or other than family members2-Identified, Resiliency-Ability to identify and use strengths in managing their lives,2-Identified and Resourceful, 3-Identified. There was no explanation as to why these areas were listed as strengths.

Patient C3's treatment plan dated 6/22/18 listed Family, 2-Identified and Optimism, 2-Identified. There was no explanation as to why family and optimism were listed as strengths.

Patient C4's treatment plan dated 6/11/18 did not list any strengths.

B. Policy Review

The Hospital Inpatient Services Procedures/Standards of Care Manual-SOC #4.0.0, Date last revised 4/17 stated: "Each treatment plan contains the substantiated diagnosis, ide

Based on medical record review, policy review and staff interview, the facility failed to provide short-term and long-tern goals that were individualized for eight (8) of eight (8) sample patients (M1, M2, M3, M4, C1, C2, C3, C4). This failure hinders the ability of the treatment team to recognize that the goals need to be individualized based on the patient's diagnosis and presenting problems and may hinder the team's ability to modify the patient's individual short and long-term objectives. In addition, the hospital's average length of stay is 7-9 days yet the target dates for the objectives were approximately 3 (three) months. The listed objectives were defined by each discipline, service or group modality, and the documented statements of the "objective and completion criteria" were identical for some disciplines for all of the sample patients.

Findings include:

A. Record Review

Patient M1 was admitted on 6/04/18 with a diagnosis of schizophrenia; Multiple episodes, currently in acute episode and a treatment plan dated 6/06/18. Objective and Completion Criteria was" (Patient Name) will identify individual needs for discharge from IPU, including living arrangements, transportation home at discharge, and follow up appointments with a target date of 9/04/18 "and "(Patient Name) will attend Skills and Education Group, including Seeking Safety, to demonstrate ability to stay on task and provide reality-based comments", with a target date of 9/09/18.

Patient M2 was admitted on 6/06/18 with a diagnosis of Bipolar 1 Disorder; With mood-congruent psychotic features and a treatment plan dated 6/08/18. Objective and Completion Criteria was "(Patient Name) will identify individual needs for discharge from IPU, including living arrangements, transportation home at discharge, and follow up appointments", with a targ

Based on record review, policy review and staff interview, the facility failed to ensure that the Master Treatment Plan (MTP) included comprehensive nursing interventions for eight (8) of eight (8) patients (M1, M2, M3, M4, C1, C2, C3, C4), comprehensive medical interventions for eight (8) of eight (8) (M1, M2, M3, M4, C1, C2, C3, C4) patients and individualized social work interventions for eight (8) of eight (8) active sample patients to address the patient's complex treatment needs (M1, M2, M3, M4, C1, C2, C3, C4) . The social work (case management) interventions listed on the Master Treatment Plan (MTP), referred to as the "Treatment Plan" in the facility do not reflect individualized care planning interventions rather include interventions that would be expected to be regularly provided for all patients. The nursing interventions listed on the patients' MTP do not address interventions beyond medication and symptom education provided to all patients daily by the nurse. The treatment interventions failed to include the focus of managing symptoms that resulted in hospitalization and patient medical care needs. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning, specifically interventions necessary to provide active treatment. The hospital's average length of stay was reported to be 7-9 days yet the target dates for interventions were approximately 3(three) months.

Findings include:

A. Record Review:

Patient C1 (Admitted 5/15/18, MTP 5/22/18). Patient problem identified in the MTP: "(Patient Name) presented with symptoms of schizophrenia as evidenced by his/her being admitted to IPU (Inpatient unit) on emergency detention which states 'he/she has history of paranoid schizophrenia'. (Patient Name) also receives treatme

Based on record review and staff interview the Medical Director failed to ensure that:

I. The Psychiatric Evaluations included memory and intellectual functioning for all eight (8) active sample patients. (M1, M2, M3, M4, C1, C2, C3, C4). Refer to B116

II. The Psychiatric Evaluation included an inventory of patients' assets/strengths for seven (7) out of eight (8) active sample patients (M1, M2, M3, M4, C1, C3, C4). Refer to B117

III. Ensure that the Master Treatment Plan (MTP) included an inventory of the patient's strengths for eight (8) of eight (8) active sample patients (M2, M3, M4, C1, C2, C3, and C4). This failure impacts identification of how patient strengths will be utilized in treatment. Refer to B119

IV. Ensure that clinical staff provided Master Treatment Plans (MTP) that identified individualized short term (ST) and long term (LT) goals stated for eight (8) of eight (8) active sample patients (M1, M2, M3, M4, C1, C2, C3, and C4). This failure hinders the ability of the treatment team to recognize that the goals need to be individualized based on the patient's diagnosis and presenting problems and may hinder the team's ability to modify the patient's individual short and long-term objectives. In addition, the hospital's average length of stay is 7-9 days yet the target dates for the objectives were approximately 3 (three) months. Refer to B121

V. Ensure that the Master Treatment Plan (MTP) included comprehensive physician, nursing and social work treatment interventions for eight (8) of eight (8) sample patients. These interventions do not reflect individualized care planning interventions rather include interventions that would be expected to be regularly provided for all patients. The listed interventions did not address necessary nursing interventions beyond patient educatio

Based on record review and staff interviews, it was determined that the Director of Nursing does not have sufficient education and experience for her current administrative position as Nurse Executive in the facility. This deficient practice can result in lack of quality nursing care for the patients.

Findings include:

A. Document Review

A Review of the Director of Nursing's curriculum vitae revealed that the Director of Nursing had a Master of Science in Management with Health Care Specialization Degree completed March 2013. Her job history highlighted work experience in mental health care settings in a variety of roles since 2000, including Director of Nursing, Nurse Manager, Director of Clinical Services, Director of Behavioral Health.

B. Interview

During an interview on 6/26/18 at 4:00 p.m., the Director of Nursing (DON) stated that she had applied to a Psychiatric Mental Health Nursing program at the same time she applied for the Management with Health Care Specialization Program (MSM-HC) at Wesleyan University, but got right into the Health Care Management program. She graduated from Wesleyan University in 2013 with her degree in Management with Health Care Specialization Program. She stated that she recently was accepted to an MSN program at Wesleyan University and was going to be starting in the program. She said that she he had about 25 years total mental health nursing experience. The Director of Nursing was asked to provide any additional education and training, or any consultation she may have with a Clinical Nurse Specialist or the Psychiatric Nurse Practitioner, specializing in Mental Health Nursing to meet the training and education component. No additional training and education or consultation information was submitted.

Based on record review and interview, it was determined that the Director of Nursing (DON) failed to ensure the quality of nursing input in the development of the Master Treatment Plan (MTP), specifically to identify comprehensive and relevant nursing interventions to manage patient symptoms and care for the patient's medical needs. Restraint was documented in the MTP with interventions, however the identified interventions were procedural expectations. The interventions listed on MTP's for eight (8) of eight (8) active sample patients (C1, C2, C3, C4, M1, M2, M3 and M4) do not address nursing interventions beyond medication and symptom education provided to all patients daily by the nurse. The treatment interventions failed to include the focus of managing symptoms that resulted in hospitalization and patient medical care needs. The MTP's for two (2) of eight (8) active patients (C4, M3) contained restraint use interventions. These deficiencies result in treatment plans that do not reflect individualized, integrated and comprehensive multidisciplinary treatment planning, specifically interventions necessary to provide active treatment. The hospital's average length of stay is 7-9 days yet the target dates for the interventions were approximately 3 (three) months. Refer to B122

I. Based on medical record review and staff interview the Director of Social Work failed to ensure quality and oversight of the psychosocial assessments provided by the social work staff. The psychosocial assessments did not include a summary of the findings, conclusions and recommendations that described social work role in treatment and discharge planning in all active sample patients (M1, M2, M3, M4, C1, C2, C3, C4). Refer to B108

II. Social Work (Case Management) Goals and Objectives in the MTP for eight (8) of eight (8) patients (M1, M2, M3, M4, C1, C2, C3, C4) were the same or similar and reflected social work duties for discharge planning rather than individualized patient treatment objectives. Refer to B121