HospitalInspections.org

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to Complaint conducted on November 14 - 15, 2016, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on document review and interview, it was determined, for 2 of 2 psychiatric patients (Pts. #3 & 4) on the 4th floor Intensive Treatment Unit (4 ITU)), the Hospital failed to ensure 15 minute safety rounding sheets (Patient Observation Records) were available and complete.

Findings include:

1. On 11/14/16 at 10:30 AM, a Patient Observation Record (15 minute safety rounding sheet) was reviewed. The form included areas in which to document, every 15 minutes, the patient's location, observer's initials, and patient's mood ("angry, agitated, hyperactive, isolating, worried/ anxious, socializing, calm/ composted").

2. On 11/15/16 at 2:40 PM, the Hospital policy titled, "Safety Rounds", revised September 2016, was reviewed. The policy required, "In order to insure the safety and security of all program units, unit staff on a routine basis conducts safety rounds...A Patient Observation Record is completed every 15 minutes..." The policy did not include documenting the patient's mood.

3. On 11/14/16 at 11:10 AM, Pt. #3's clinical record was reviewed. Pt. #3 was a 61 year old male, admitted on 11/7/16, with a diagnosis of schizophrenia. The clinical record lacked Pt #3's safety observation sheet for 11/8/16.

4. Pt. #3's fifteen minute safety observation sheets dated 11/9/16 through 11/13/16 lacked documentation of Pt. #3's mood on the following dates and times:

11/9/16 7:30 PM to 10:30 PM
11/10/16 12:00 PM to 1:45 PM
11/10/16 6:15 PM to 8:30 PM
11/11/16 3:30 PM to 5:00 PM
11/12/16 7:30 AM to 2:30 PM
11/12/16 7:00 PM to 11:00 PM
11/13/16 9:45 AM to 1:00 PM
11/13/16 6:45 PM to 11:00 PM

5. On 11/14/16 at 2:30 PM, #4's clinical record was reviewed. Pt. #4 was a 75 year old female, admitted on 11/11/16, with a diagnosis of schizophrenia. Pt. #4's safety observations sheets lacked documentation of Pt. #4's mood on the following dates:

11/12/16 7:30 AM to 11:00 PM
11/13/16 7:30 AM to 3:15 PM
11/13/16 6:30 PM to 11:00 PM

6. On 11/14/16 at 10:20 AM, an interview was conducted with a Nursing Supervisor (E #7). E #7 stated the 15 minutes safety sheet for Pt. #3 could not be located and the mood of the patient should be documented on the 15 minute safety sheets, except on the night shift, when the patients are sleeping.

Based on document review and interview, it was determined for 1 of 2 (Pt. #16) patient records reviewed regarding use of restraint or seclusion, the Hospital failed to ensure the time frame for the seclusion order was specified.

Findings include:

1. On 11/15/16 at approximately 11:30 AM, the clinical record for Pt. #16 was reviewed. Pt. #16 was a 60 year old male admitted on 11/05/16 with the diagnosis of schizoaffective disorder. Pt. #16's clinical record included an order for seclusion on 11/9/16. However, the time frame for seclusion was not included in the physician order.

2. On 11/16/16 at approximately 10:30 AM, the Hospital's policy entitled, "Use of Restraint and Seclusion" (revised 10/2015) indicated, "...J. The Order Sheet for Restraint/Seclusion shall contain the following:...d. the length of time...i. adults: up to 4 hours... Special Note: The time limits specified are maximums; use of Restraint/Seclusion should be limited to the duration of Emergency Safety..."

3. On 11/15/16 at approximately 11:30 AM, the finding was discussed with E # 10 (Manager of the 3 North East Unit). E # 10 acknowledged that the time frame for the seclusion on 11/9/16 was not selected in the order.

Based on document review and interview, it was determined for the Health Information Management Department, the Hospital failed to ensure medical records were complete within 30 days of discharge.

Findings include:

1. The Medical Staff Bylaws, Rules and Regulations (reviewed 12/2014) was reviewed on 11/16/16 at approximately 9:30 AM and required, "...The record will be considered delinquent if the medical record is incomplete thirty (30) days after discharge..."

2. On 11/16/16 at approximately 10:30 AM, the Manager of Health Information Management (E #13) presented the surveyor with a letter of attestation which included, "...the attached medical records report reflects chart delinquency for the week ending 11/12/2016." The attachment included the total delinquent records was 212.

3. During an interview with E #13 on 11/16/16 at approximately 10:30 AM, E #13 stated the medical records should be complete within 30 days after discharge.

Based on document review, observation, and interview, it was determined for 1 of 3 adult psychiatric units (4th floor Intensive Care Treatment Unit (4 ICTU)), the Hospital failed to ensure narcotics were secured, as required by policy, potentially affecting 19 psychiatric patients on census on 4 ICTU on 11/14/16.

Findings include:

1. On 11/15/16 at 2:00 PM, the Hospital policy entitled, "Controlled Substances", reviewed January 2015, was reviewed. The policy required, "D. Storage of Controlled Substance Drugs: Controlled substance drugs are stored in a locked, secure place within the drug storage room..."

2. On 11/14/16 between 10:00 AM and 12:20 PM, an observational tour was conducted on the 4 ICTU. In the medication room, there were 4 unlocked drawers containing controlled substances including: 9 tablets of Adderall (treat attention deficit hyperactivity disorder (ADHD)) 5 mg., 11 tablets of Ativan (treat anxiety disorder) 0.5 mg., 11 tablets of Ativan 1 mg., 7 tabs of Ativan of 2 mg., 1 tab of Klonopin (treat seizure disorder) 0.5 mg., 16 tablets of Klonopin (anti-psychotic) 1 mg., 16 tablets of Klonopin 2 mg., 22 tablets of Methadone (treat withdrawal symptoms from opiods i.e. Heroin) 10 mg., 16 tablets of Norco (treat pain) 5/325, 12 tablets of Norco 10/325, 49 tablets of Oxy IR (Oxycodone) (treat pain) 5 mg., 81 tablets of Ritalin (treat ADHD) 10 mg., 18 tablets of Phenobarbital (treat seizures) 30 mg., 32 tablets of Phenobarbital 60 mg., 10 tablets of Restoril (treat insomnia) 15 mg., 15 tablets of Restoril 30 mg., 11 tablets of Tranxene (treat anxiety) 15 mg., 11 tablets of Ultram (treat pain) 50 mg., 8 tablets of Valium (treat anxiety) 5 mg., 10 tablets of Xanax (treat anxiety) 0.25 mg., 14 tablets of Xanax 0.5 mg., and 30 tablets of Xanax 1 mg. An unlocked medication refrigerator contained 10 injectable Ativan (anti-anxiety) vials 2 mg/ml.

3. On 11/14/16 at 10:20 AM, an interview was conducted with the 4 ICTU Registered Nurse (RN-E #5). E #5 stated the key to the narcotic drawers was lost "a couple of days ago" by a nurse, and the medication refrigerator key was also missing. The narcotic drawers could not be locked and the narcotics had not been moved to a secure location.

Based on observation, document review, and interview it was determined for 2 of 2 staff (E# 16 and E #17) in the food preparation room, the Hospital failed to ensure adherence to the dress code policy. This potentially affected all patients on census, who received meals from the kitchen.

Findings include:

1. On 11/16/16 at approximately 11:00 AM, an observational tour of the food preparation area was conducted. During the tour, E #'s 16 (Food Service Manager) and 17 (Dietitian) were wearing hairnets with hair exposed around the forehead, ears, and neck.

2. On 11/16/16 at approximately 1:00 PM, the Hospital's policy entitled, "Infection Control" (no revised date) indicated, "...Personnel: Employees shall be expected to... have clean hair (covered with a hair net)..."

3. On 11/16/16 at approximately 11:30 AM, this finding was discussed with E #16 (Food Services Manager). E #16 stated that, "hair should not be exposed."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to Complaint conducted on November 14 - 15, 2016, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observational tour, and interview, it was determined, for 2 of 2 patient rooms (Rooms 224 & 225) on the second floor Chemical Dependency Unit, the Hospital failed to ensure patient rooms were properly disinfected, potentially affecting 36 patients on census.

Findings include:

1. On 11/15/16 at 2:15 PM, Hospital procedure titled, "Housekeeping Cleaning Procedure", with no approval or review date, was reviewed. The procedure required, "Procedure: 1. Patient Rooms... d. Dust and wet mop floor... 2. Patient Restrooms... e. Scrub shower, toilet - dry all surfaces..." The policy contradicted the disinfectant manufacturer requiring the disinfected surface dry and not be wiped off,

2. On 11/15/16 at 2:20 PM, Hospital practice titled, "Routine Housekeeping Practices", with no approval or review date, was reviewed. The practice required, "Procedures: 1. Disinfectant/ Germicide... Disinfectant for bucket use must be changed every three to four rooms."

3. On 11/15/16 between 10:00 AM and 11:30 AM, an observational tour was conducted on the 2nd floor Chemical Dependency Unit. A Housekeeper (E #15) was cleaning adjoining rooms 224 & 225. E #15 did not dry mop the floors, as required by policy.

4. E #15 wet mopped both rooms (224 & 225) and the shared bathroom with a dirty wet mop using dirty green/brown fluid from a mop bucket.

5. When cleaning the toilet in the shared bathroom, E #15 poured disinfectant into the toilet bowl and brushed the inside of the bowl, then brushed the the toilet seat, cleaning from a more dirty to a less dirty surface with the same equipment.

6. On 11/15/16 at 10:30 AM, an interview was conducted with (E #15). E #15 stated he had cleaned 6 rooms prior to the two being observed, not changing mop heads or mop bucket solution. E #15 stated he changes mop heads twice a day and the mop bucket solution 2 to 3 times a day.

7. On 11/15/16 at 3:15 PM, an interview was conducted with the Facility Manager (E #12). E #12 stated the mop and disinfectant should be changed after each room.


B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 urine specimen in the specimen refrigerator on the second floor Chemical Dependency Unit, the Hospital failed to ensure urine specimen containers were labeled to identify the patient, date and time of collection, potentially affecting 36 patients on census.

Findings include:

1. On 11/16/16, Hospital policy titled, "Laboratory Services/ Critical Test Results", effective October 2015, was reviewed. The policy required, "II. Procedure... c) All specimens are stored in the lab refrigerator. Specimens are picked up daily by contractual lab." The policy did not indicate if labeling of the specimen container was necessary.

2. On 11/15/16 between 10:00 AM and 11:30 AM, an observational tour was conducted on the 2nd floor Chemical Dependency Unit. The specimen refrigerator contained 1 unlabeled urine specimen.

3. On 11/15/16 at 10:50 AM, an interview was conducted with the Charge Nurse (E #14) on the Chemical Dependency Unit. E # 14 stated the urine specimen was probably collected by the night shift and should have been labeled. E #14 did not know which patient the urine collection came from.

C. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Registered Nurse (E #14) on the second floor Chemical Dependency Unit, the Hospital failed to ensure the Nurse allowed the alcohol skin preparation to dry before administering medication by needle injection.

Findings include:

1. On 11/15/16 at 2:30 PM, Hospital document titled, "Intramuscular Injection Competency Assessment and Verification", created on 10/19/16, was reviewed. The policy required, "11. Administering IM injection... g. Selects appropriate injection site, clean the site with alcohol pad and allow skin to dry..." The policy did not provide instruction on how long to wait for alcohol to dry.

2. On 11/15/16 between 10:00 AM and 11:30 AM, an observational tour was conducted on the 2nd floor Chemical Dependency Unit. At 10:40 AM, the Charge Nurse (E #14) instructed Pt. #13 he would receive an Ativan injection for tremors. Pt. #13 pulled down his pants and E #14 rubbed an alcohol pad on Pt. #13's right buttox. E #14 administered the medication before the alcohol had dried, within 7 seconds.

3. On 11/15/16 at 10:50 AM, an interview was conducted with E #14. E #14 stated he waited 15 seconds after applying the alcohol prep, before administering the medication.


36774

A. Based on observation, document review, and interview, it was determined for 1 of 2 refrigerators (Day Room refrigerator) used to store patient's food and beverages on the 3 North East Unit, the Hospital failed to ensure cleanliness of the refrigerator as required by policy. This potentially affected all 18 patients on the unit's census.

Findings include:

1. On 11/15/16 at approximately 10:30 AM, an observational tour of the 3rd floor North East Unit. The refrigerator in the Day Room used to store patients' snacks such as juice, milk, and crackers was noted to have molds on the inside upper part of the refrigerator door.

2. On 11/15/16 at approximately 1:30 PM, the Hospital's policy titled "Refrigerator Cleaning Policy" (no date reviewed) indicated, "Purpose: To ensure hospital refrigerators in ...patient kitchens are cleaned... Procedure: ...4. The Dietary Department Manager assigns staff to clean the refrigerator using the appropriate product weekly on a rotating basis as needed."

3. On 11/65/16 at approximately 10:00 AM, an interview was conducted with E #16 (Dietary Manager) who stated that, "it is my responsibility to ensure the cleanliness of the refrigerator in the Day Room." E # 16 added that, "the refrigerator should have been cleaned."

B. Based on observation, document review, and interview, it was determined for 1 of 1 (dry goods) storage room, the Hospital failed to ensure adherence to food storage area policy as required. This potentially affected all patients on the hospital census.

Findings include:

1. On 11/16/16 at approximately 11:00 AM, an observational tour of the kitchen was conducted. During the tour, it was noted there were 7 personnel outerwear jackets and 1 backpack hanging inside the dry goods storage area.

2. On 11/16/16 at approximately 1:00 PM, the Hospital's policy titled, "Food Storage" (no revision date) indicated, "Policy:... All dry foods are stored in storeroom that is clean..."

3. On 11/16/16 at approximately 1:00 PM, the Hospital's policy titled, "Infection Control" (no revised date) indicated, "Infection Control Practices:... Storage areas shall be... cleaned thoroughly weekly and inspected daily..."

4. On 11/16/16 at approximately 11:05 AM, finding was discussed with E #16 who stated that the outerwear jackets and bag should have not been kept inside the dry goods storage room.

Based on medical record review and staff interview it was determined that for eight (8) of 10 patients their Psychiatric Evaluation failed to include an assessment of the patient's assets in descriptive not interpretive fashion. This failure results in the treatment team not being aware of possible interests, accomplishments, or other assets that might be utilized in therapeutic endeavors. (Patients A1, A2, A3, A4, A5, B1, B2 and, B3) The findings include---

I. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 11/11/16 stated as the patient's sole asset "Stable Housing".

2. Patient A2: The Psychiatric Evaluation dated 11/09/16 stated as the patient's assets "Supportive Family/Friends" and "Religious Affiliation".

3. Patient A3: The Psychiatric Evaluation dated 11/13/16 stated as the sole patient asset "Stable Housing".

4. Patient A4: The Psychiatric Evaluation dated 11/09/16 had no assessment of patient assets.

5. Patient A5: The Psychiatric Evaluation dated 11/10/16 had no assessment of patient assets.

6. Patient B1: The Psychiatric Evaluation dated 10/25/16 had no assessment of patient assets.

7. Patient B2: The Psychiatric Evaluation dated 10/17/16 had as the sole patient asset "Physical Health".

8. Patient B3: The Psychiatric Evaluation dated 10/07/16 had as patient assets "Stable Housing" and "Physical Health".

II. Staff Interview:

On 11/15/16 at 3:00p.m. the Clinical Director was interviewed. When the findings described in Section I above were discussed, he concurred the assessments of patient assets were not individualized, inherent attributes that might possibly be utilized in treatment modalities.

Based on medical record review and staff interview it was determined that for 10 of 10 patients the facility failed to ensure that Treatment Plans were developed and/or determined after information from the psychiatric evaluation and the assessments/ diagnostic data collected by the multidisciplinary treatment team members was available. This failure results in a Treatment Plan that is not based on all available information. (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5). The findings include---

1. Patient B5: This 11 year old male was admitted onto the Unit on 10/26/16 at 5a.m. The admitting nurse at that time based on an initial nursing assessment formulated three (3) Problems "Aggressive Bx's (behaviors)", "Poor Impulse Control" and "Alteration in Mood-Depressed" on what would become the Master Treatment Plan for this hospitalization. In addition, the preprinted modalities (Section "Planned Treatment Modalities") for each of the three (3) Problems were selected by the nurse for the disciplines of medicine, social work and nursing. There was no evidence of collaboration on determining priorities or special focus in an individualized patient specific manner.

2. Patient B1: This 13 year old female was admitted on 10/14/16. The Master Treatment Plan was signed by the attending psychiatrist on 10/31/16. The Treatment Plan Review of Patient B1 dated 11/07/16 was unsigned by the attending psychiatrist at the time of the survey 11/14/16.

3. Patient B2: This 16 year old female was admitted on 10/16/16. Problem 1 on the Master Treatment Plan had been determined by the admitting nurse on 10/16/16. The next three (3) Problems were selected by the social service staff member on 10/17/16. This Master Treatment Plan as of 11/14/16 is unsigned by the attending psychiatrist.

II. Staff Interview:

On 11/14/16 at 1:10p.m. Social Worker #2 was interviewed. Social Worker #2 affirmed that it is the responsibility of the social service member of the treatment team to "fill out the Treatment Plan" and thus assign the interventions to the psychiatrist, nurse and therapist.

On 11/15/16 at noon the nurse manager of the Pavilon Building was interviewed. The manager affirmed that Problem selection is done by a nursing staff member at admission and that social service staff fill out the treatment plan assigning interventions to nursing and physician staff.

See, B 122 for Modalities: uniform and lacking individualization.

See, B 123 for Responsible Staff for details.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of interventions with a specific focus based on individual needs of 10 of 10 active sample patients (A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5). Active sample patient A3's interventions for the problem "Risk for Self-Harm" were missing on the MTP dated 11/12/16. Specifically, this review revealed that the preprinted MTPs contained the same list of interventions for each discipline (physician, nurses, and social work staff) based on the identified problem listed. The intervention statements were normal clinical functions and did not reflect any active treatment interventions to assist patients to improve their presenting psychiatric problems identified in clinical assessments. None of the plans listed any specific group modalities related to any patient's specific interventions and purpose for each. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal directed.

Findings include:

A. Record Review

Facility policy, titled "Master Treatment Plan", dated 10/21/14, stated, "Modalities are defined on the Master Treatment Plan in terms of frequency, duration, and staff responsible." There were no other descriptions about what these modalities (interventions) should include.

All of the interventions that are described below were identical per Problem listed regardless of each patient's individual needs.

1. Active sample patient A1: The MTP dated 11/11/16, had as a Problem, "Substance Abuse". No interventions were identified for this Problem.

For the Problem "Potential for Relapse", the interventions were:

- "Psychiatrist to assess mood, mental status, insight regarding illness, motivation for treatment, completion of assignments."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med [medication] compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery."

2. Active sample patient A2: The MTP dated 11/9/16, had as Problem "Disturbed Thought Process". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [Suicidal Ideations], presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antipsychotic medications/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

3. Active sample patient A3: The MTP dated 11/12/16, had the Problem "Risk for Self-Harm". There were no interventions for this Problem listed in the chart for patient A3.

4. Active sample patient A4: The MTP dated 11/8/16, had the Problem "Alteration in Mood: Manic/Hypomanic". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI [suicidal ideations], presence of suicidal plan, affect, need for increased observation level, orientation stage of elation - (hypomanic, manic, psychotic), effectiveness of: antidepressant medications/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thoughts Process", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [Suicidal Ideations], presence of HI [homicidal ideations], affect, need for increased observation level, effectiveness of antipsychotic medications/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

5. Active sample patient A5: The MTP dated 11/9/16, had the Problem "Alteration in Mood - Depressed". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI (Suicidal Ideations], presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Risk for Self-Harm", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI, presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

6. Active sample patient B1: The MTP dated 10/14/16, had the Problem "Risk for Self-Harm". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI, presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Aggressive Behavior", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set demonstration."

For the Problem of "Poor Impulse Control", the interventions were:

- "Psychiatrist to assess: mood, mental status, level of anxiety, presence of HI [Homicidal Ideations], affect, orientation, need for increased observation level, effectiveness of antianxiety medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

7. Active sample patient B2: The MTP dated 10/17/16, had the Problem "Risk for Self-Harm". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI, presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Depressed", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI [Suicidal Ideations], presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Substance Abuse", the interventions were:

- "Psychiatrist to assess: mood, mental status, family history, affect, insight into substance use/abuse, issues, potential withdrawal signs/symptoms, effectiveness of detox process."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of HI [Homicidal Ideations], affect, orientation, need for increased observation level, effectiveness of antianxiety medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thought Process", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [suicidal ideations], presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antipsychotic medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

8. Active sample patient B3: The MTP dated 10/7/16, had the Problem "Aggressive Behavior". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control". The interventions were:

- "Psychiatrist to assess: mood, mental status, level of anxiety, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antianxiety medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Depressed", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of suicidal SI [Suicidal Ideations], presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thought Process", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [Suicidal Ideations], presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antipsychotic medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

9. Active sample patient B4: The MTP dated 11/3/16, had the Problem "Risk for Self-Harm". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of SI, presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medications."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Aggressive Behavior", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thought Process", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [suicidal ideations], presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antipsychotic medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control", the interventions were:

- "Psychiatrist to assess: mood, mental status, level of anxiety, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antianxiety medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Anxiety", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of internal stimuli, orientation, presence of SI [suicidal ideations], presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antianxiety medications/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

10. Active sample patient B5: The MTP dated 10/26/16, had the Problem "Aggressive Behavior". The interventions were:

- "Psychiatrist to assess: mood, mental status, presence of HI, Affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control", the interventions were:

- "Psychiatrist to assess: mood, mental status, level of anxiety, presence of HI [Homicidal Ideations], affect, need for increased observation level, effectiveness of antianxiety medication/mood stabilizing medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Depressed", the interventions were:

- "Psychiatrist to assess: mood, mental status, presence of suicidal SI [Suicidal Ideations], presence of suicidal plan, affect, need for increased observation level, effectiveness of antidepressant medication."

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."


B. Interview

1. In an interview on 11/15/16 at 10:16 a.m., the generic and identical interventions on the Master Treatment Plans per identified Problem, regardless of each patient's individual needs, was discussed with Social Worker #1. She did not dispute the findings.

2. In an interview on 11/15/16 at 2:50p.m., the identical/similar interventions on each patient's treatment plan was discussed with the Nursing Director. She stated, "I fully understand what you are saying. I'm in the process of working with the nurses to improve this problem."

3. In an interview on 11/15/16 at 3:00p.m., the identical and/or similar intervention on each patient's treatment plan was discussed with the Medical Director. He agreed with the findings.

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Multidisciplinary Treatment Plans for 10 of 10 treatment plans of active sample patients (A1, A2, A3, A4, A5, B1, B2, B3, B4, and B5). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

Review of the following Multidisciplinary Treatment Plans (dates of the plan in parenthesis) revealed that they did not delineate the names and responsibilities of treatment team member, only the discipline, such as psychiatrist, nursing, and therapists (social work staff): A1 (11/1116), A2 (11/916), A3 (11/12/16), A4 (11/8/16), A5 (11/9/16), B1 (10/21/16), B2 (10/17/16), B3 (10/7/16), B4 (11/3/16) and B5 (10/26/16).


B. Interview

In an interview on 11/16/16 at 8:50 a.m., the lack of using specific names of staff, instead of just the discipline, was discussed with the Social Work Director. She stated she was aware of the problem and was working on this change, along with improvement in the treatment interventions.

Based on medical record review and staff interview it was determined that for 10 of 10 patients the Clinical Director failed to ensure (1) the Psychiatric Evaluations contained an assessment of assets in descriptive not interpretive fashion and (2) that Master Treatment Plans were established after psychiatric, medical and social service assessments were done and (3) that Master Treatment Plans and/or Treatment Plan Reviews were signed by the attending psychiatrist in a timely manner. (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5). The findings include----

1. Based on medical record review and staff interview it was determined that for eight (8) of 10 patients their Psychiatric Evaluation failed to include an assessment of the patient's assets in descriptive not interpretive fashion. This failure results in the treatment team not being aware of possible interests, accomplishments, or other assets that might be utilized in therapeutic endeavors. (Patients A1, A2, A3, A4, A5, B1, B2, and B3). The findings include---

I. Medical Record Review:

(1) Assets not determined:
1. Patient A1: The Psychiatric Evaluation dated 11/11/16 stated as the patient's sole asset "Stable Housing".

2. Patient A2: The Psychiatric Evaluation dated 11/0916 stated as the patient's assets "Supportive Family/ Friends" and "Religious Affiliation".

3. Patient A3: The Psychiatric Evaluation dated 11/13/16 stated as the sole patient asset "Stable Housing".

4. Patient A4: The Psychiatric Evaluation dated 11/09/16 had no assessment of patient assets.

5. Patient A5: The Psychiatric Evaluation dated 11/10/16 had no assessment of patient assets.

6. Patient B1: The Psychiatric Evaluation dated 10/25/16 had no assessment of patient assets.

7. Patient B2: The Psychiatric Evaluation dated 10/17/16 had as the sole patient asset "Physical Health".

8. Patient B3: The Psychiatric Evaluation dated 10/07/16 had as patient assets "Stable Housing" and "Physical Health".

II. Staff Interview:

On 11/15/16 at 3:00p.m. the Clinical Director was interviewed. When the findings described in Section I, above were discussed he concurred that the assessments in their descriptions of patient assets were not individualized, inherent attributes that might possibly be utilized in treatment modalities.

(2) Treatment Plans not a collaborative effort:

Based on medical record review and staff interview it was determined that for 10 of 10 patients the Clinical Director failed to ensure that Treatment Plans were developed and/or determined after information from the psychiatric evaluation and the assessments/diagnostic data collected by the multidisciplinary treatment team members was available. This failure results in a Treatment Plan that is not based on all available information. (Patients A1, A2, A3, A4, A5, B1, B2, B3, B4 and B5). The findings include---

1. Patient B5: This 11 year old male was admitted onto the Unit on 10/26/16 at 5a.m. The admitting nurse at that time based on an initial nursing assessment formulated three (3) Problems "Aggressive Bx's (behaviors)", "Poor Impulse Control" and "Alteration in Mood-Depressed" on what would become the Master Treatment Plan for this hospitalization. In addition the preprinted modalities (Section "Planned Treatment Modalities") for each of the three (3) Problems were selected by the nurse for the disciplines of medicine, social work and nursing. There was no evidence of collaboration on determining priories or special focus in an individualized patient specific manner.

2. Patient B1: This 13 year old female was admitted on 10/14/16. The Master Treatment Plan was signed by the attending psychiatrist on 10/31/16. The Treatment Plan Review of Patient B1 dated 11/07/16 was unsigned by the attending psychiatrist at the time of the survey 11/14/16.

3. Patient B2: This 16 year old female was admitted on 10/16/16. Problem1 on the Master Treatment Plan had been determined by the admitting nurse on 10/16/16. The next three (3) Problems were selected by the social service staff member on 10/17/16. This Master Treatment Plan as of 11/14/16 is unsigned by the attending psychiatrist.

II. Staff Interview:

On 11/14/16 at 1:10p.m. Social Worker #2 was interviewed. Social Worker #2 affirmed that it is the responsibility of the social service member of the treatment team to "fill out the Treatment Plan" and thus assign the interventions to the psychiatrist, nurse and therapist.

(3) Treatment Plans unsigned by attending psychiatrist:

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Multidisciplinary Treatment Plans for 10 of 10 treatment plans of active sample patients (A1, A2, A3, A4, A5, B1, B2, B3, B4, and B5). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

Review of the following Multidisciplinary Treatment Plans (dates of the plan in parenthesis) revealed that they did not delineate the names and responsibilities of treatment team member, only the discipline, such as psychiatrist, nursing, and therapists (social work staff): A1 (11/11/16), A2 (11/9/16), A3 (11/12/16), A4 (11/8/16), A5 (11/9/16), B1 (10/21/16), B2 (10/17/16), B3 (10/7/16), B4 (11/3/16) and B5 (10/26/16).


B. Interview

In an interview on 11/16/16 at 8:50 a.m., the lack of using specific names of staff, instead of just the discipline, was discussed with the Social Work Director. She stated she was aware of the problem and was working on this change, along with improvement in the treatment interventions.

Based on record review and interview, the Nursing Director failed to develop Master Treatment plans (MTPs) that evidenced sufficient individualized planning of nursing interventions with a specific focus based on individual patient needs of nine (9) of 10 active sample patients (A1, A2, A4, A5, B1, B2, B3, B4, and B5). Specifically, this review revealed that the preprinted MTPs contained the same or similar nursing interventions regardless of the identified Problems listed. The intervention statements were normal clinical functions and did not reflect any active treatment interventions to assist patients to improve their presenting psychiatric problems identified in clinical assessments. None of the plans listed any specific group modalities related to any patient's specific interventions and purpose for each. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal directed.

Findings include:

1. Active sample patient A1: The MTP dated 11/11/16, had the Problem, "Substance Abuse". No nursing interventions were identified for this Problem.

For the Problem "Potential for Relapse", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med [medication] compliance, self-regulation skills demonstration."

2. Active sample patient A2: The MTP dated 11/9/16, had the Problem "Disturbed Thoughts Process". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

3. Active sample patient A4: The MTP dated 11/8/16, had the Problem "Alteration in Mood: Manic/Hypomanic". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Disturbed Thoughts Process", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

4. Active sample patient A5: The MTP dated 11/9/16, had the Problem "Alteration in Mood - Depressed". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration orientation."

For the Problem "Risk for Self-Harm", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

5. Active sample patient B1: The MTP dated 10/14/16, had the Problem "Risk for Self-Harm". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Aggressive Behavior", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem of "Poor Impulse Control", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

6. Active sample patient B2: The MTP dated 10/17/16, had the Problem "Risk for Self-Harm". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Alteration in Mood - Depressed", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration orientation."

For the problem of "Substance Abuse", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

For the Problem "Poor Impulse Control", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Disturbed Thought Process", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

7. Active sample patient B3: The MTP dated 10/7/16, had the Problem "Aggressive Behavior". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem of "Poor Impulse Control". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Alteration in Mood - Depressed", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Disturbed Thought Process", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

8. Active sample patient B4: The MTP dated 11/3/16, had the Problem "Risk for Self-Harm". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Aggressive Behavior", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Disturbed Thought Process", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

For the Problem "Poor Impulse Control", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Alteration in Mood - Anxiety", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration, orientation."

9. Active sample patient B5: The MTP dated 10/26/16, had the Problem "Aggressive Behavior". The nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Poor Impulse Control", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."

For the Problem "Alteration in Mood - Depressed", the nursing interventions were:

- "Nursing to assess: mood, change in behavior, presence of suicidal plan, observation level, med compliance, self-regulation skills demonstration."


B. Interview

In an interview on 11/15/16 at 2:50 p.m., the identical/similar interventions on each patient's treatment plan was discussed with the Nursing Director. She stated, "I fully understand what you are saying. I'm in the process of working with the nurses to improve this problem."

Based on record review and interview, the Director of Social Work failed to develop Master Treatment Plans (MTPs) that evidenced sufficient individualized planning of social work interventions with a specific focus based on individual needs of nine (9) of 10 active sample patients (A1, A2, A4, A5, B1, B2, B3, B4, and B5). Specifically, this review revealed that the preprinted MTPs contained the same social work interventions regardless of the identified problems listed. The intervention statements were normal clinical functions and did not reflect any active treatment interventions to assist patients to improve their presenting psychiatric problems identified in clinical assessments. None of the plans listed any specific group modalities related to any patient's specific interventions and purpose for each. These failures hamper staff's ability to provide individualized treatment that is purposeful and goal directed.

Findings include:

A. Record Review

1. Active sample patient A1: The MTP dated 11/11/16, had for the Problem "Potential for Relapse", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery."

2. Active sample patient A2: The MTP dated 11/9/16, had the Problem "Disturbed Thoughts Process". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

4 Active sample patient A4: The MTP dated 11/8/16, had the Problem "Alteration in Mood: Manic/Hypomanic". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thoughts Process", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

4. Active sample patient A5: The MTP dated 11/9/16, had the Problem "Alteration in Mood - Depressed". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Risk for Self-Harm", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

5. Active sample patient B1: The MTP dated 10/14/16, had the Problem "Risk for Self-Harm". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Aggressive Behavior", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set demonstration."

For the Problem of "Poor Impulse Control", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

6. Active sample patient B2: The MTP dated 10/17/16, had the Problem "Risk for Self-Harm". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem of "Alteration in Mood - Depressed", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem of "Substance Abuse", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

For the Problem of "Poor Impulse Control", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem of "Disturbed Thought Process", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

7. Active sample patient B3: The MTP dated 10/7/16, had the Problem "Aggressive Behavior". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Depressed", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thought Process", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

8. Active sample patient B4: The MTP dated 11/3/16, had the Problem "Risk for Self-Harm". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Aggressive Behavior", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Disturbed Thought Process", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Anxiety", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behavior, self-regulation skill set, use of wellness recovery plan."

9. Active sample patient B5, MTP dated 10/26/16, had as a problem "Aggressive Behavior". The social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Poor Impulse Control", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."

For the Problem "Alteration in Mood - Depressed", the social work intervention was:

- "Psych education groups to facilitate understand of [sic]: triggers leading to unwanted behaviors, self-regulation skill set, use of wellness recovery plan."


B. Interview

In an interview on 11/16/16 at 8:45 a.m., the generic social work interventions were discussed with the Director of Social Work. She stated "We are working on trying to update our treatment plan."