HospitalInspections.org

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level and condition level deficiencies related to patient rights, Quality Assurance and Performance Improvement, nursing services medical records and infection control the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with the Conditions of Participation as follows:

(482.12(c)(3), Tag-0067)
The documentation reviewed during the survey provided evidence that the facility failed to provide on-call physician coverage.

(482.13(a)(1), Tag-0117)
The documentation reviewed during the survey provided evidence that the facility failed to provide the "Important Message for Medicare on Admission and Discharge.

(482.13(b)(2), Tag-0131)
The documentation reviewed during the survey provided evidence the facility failed to provide written notice of physician coverage 24 hours a day, 7 days a week

(482.13(b)(3), Tag-0132)
The documentation reviewed during the survey provided evidence the facility failed to ensure patients had the right to form Advance Directives

(482.13(b)(4), Tag-0133)
The documentation reviewed during the survey provided evidence the facility failed to ensure, at the request of the patient, family member, patient representative or primary care doctor were notified of admission

(482.13(c)(2), Tag-0144)
The documentation reviewed during the survey provided evidence the facility failed to follow their Occupational Health Policy

(482.21(a),(b)(1),(b)(2)(i),(b)(3), Tag-0273)
The documentation reviewed during the survey provided evidence the facility failed to develop distinct performance improvement projects for services provided.

(482.21(d), Tag-0297)
The documentation reviewed during the survey provided evidence the facility failed to perform performance projects for services offered at the facility

(482.21, Tag-0308)
The documentation reviewed during the survey provided evidence that the governing body failed to establish a hospital-wide quality program

(482.23(b)(2), Tag-0386)
The documentation reviewed during the survey provided evidence that the facility failed to ensure the director of nurses met the educational requirements

(482.23(c)(1) (c)(1)(i)&(c)(2), Tag-0405)
The documentation reviewed during the survey provided evidence the facility failed to follow their own policy to administer scheduled drugs and biologicals according to the medication orders.

(482.24(b), Tag-0438)
The documentation reviewed during the survey provided evidence that the facility failed to ensure medical records were protected from fire and water damage.

(482.24(c)(4)(viii), Tag-0469)
The documentation reviewed during the survey provided evidence that the facility failed to ensure medical records were completed within 30 days after discharge.

(482.30(e), Tag-0657)
The documentation reviewed during the survey provided evidence the facility failed to perform periodic reviews for current inpatients receiving hospital services.

(482.30(f), Tag-0658)
The documentation reviewed during the survey provided evidence the facility failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available services.


(482.42(a), Tag-0748)
The documentation reviewed during the survey provided evidence that the facility failed to ensure the infection control officer was qualified to conduct the program

(482.42(a)(1), Tag-0749)
The documentation reviewed during the survey provided evidence the to develop a system for controlling infections and communicable diseases of patients.

(482.43(e), (Tag-0843)
The documentation reviewed during the survey provided evidence the failed to reassess its discharge planning process on an on-going basis.


Repeat deficency:
Event ID WNWM11 10/11/2018

Based on review of facility documents and interview with staff (EMP) it was determined the governing body failed to ensure a doctor of medicine or osteopathy was on-call at all times.

Findings include:

Review on November 3, 2019, of facility document "Governing Board Bylaws of Haven Behavioral Health Hospital of Philadelphia," revealed "Article II General Provisions, 1. Hospital Management. The Company, which owns and operates the business of the Hospital, is managed under the direction of the Member thru its officers. The role and purpose of the Hospital is to provide an organization and facility supporting qualified medical professionals in providing quality health care ... The Member has delegated certain rights and duties to the Governing Board, as set forth b these Bylaws ... Article V. Organization of the Medical Staff, The Governing Board shall organize the Physicians and AHPs (Allied Health Professional) who are granted Clinical Privileges and the Hospital ... ."



Review on December 3, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff Rules and Regulations" approved April 20, 2019, revealed "... 11.0, On-Call - There is a physician possessing skills and knowledge in behavioral health and medical services who is on-call to the Hospital on a 24-hour basis to cover assessments, admissions and emergencies ... The Medical Director shall be administratively responsible for maintaining the Hospital's on-call roster ..."


Review on November 3, 2019 of facility's on-call schedule dated December 1, 2018, to December 31, 2019, revealed a nurse practioner provided call or was scheduled to provide call on the following dates: December 21-23, 2018 and December 28-30, 2018; January 25-27, 2019; February 22-24, 2019; March 22-24, 2019 and March 29-31, 2019; April 26-28, 2019; May 24, 2019 to June 2, 2019, 2019; July 19-21, 2019; August 23-25, 2019 and August 30, 2019 to September 1, 2019; September 27-29, 2019; October 25-27, 2019; November 22-24, 2019 and November 29, 2019 to December 1, 2019; December 20-22, 2019."

Interview on December 4, 2019, at 9:50 AM with EMP1 confirmed the Medical Director was responsible for maintaining the the on-call roster. Further interview with EMP1 confirmed a doctor of medicine or osteopathy was not always on-call.

cross reference with:
482.12 Governing Body
482.13(b)(2) Patient Rights: Informed Consent

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

(482.13(a)(1), Tag-0117)
The documentation reviewed during the survey provided evidence that the facility failed to provide the "Important Message for Medicare on Admission and Discharge.

(482.13(b)(2), Tag-0131)
The documentation reviewed during the survey provided evidence the facility failed to provide written notice of physician coverage 24 hours a day, 7 days a week

(482.13(b)(3), Tag-0132)
The documentation reviewed during the survey provided evidence the facility failed to ensure patients had the right to form Advance Directives

(482.13(b)(4), Tag 0133)
The documentation reviewed during the survey provided evidence the facility failed to ensure, at the request of the patient, family member, patient representative or primary care doctor were notified of admission

(482.13(c)(2), Tag-0144)
The documentation reviewed during the survey provided evidence the facility failed to follow their Occupational Health Policy


Repeat deficency:
Event ID WNWM11 10/11/2018

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the Important Message from Medicare was provided to all patients receiving inpatient care in nine of 14 medical records reviewed (MR4, MR5, MR6, MR8, MR10, MR11, MR13, MR14, MR15).

Findings include:

Review on December 4, 2019, of facility policy "Medicare Admission Documents," approved May 20, 2018, revealed, " ... This form is to be completed twice, once at admission and again prior to discharge. At admission, it must be completed within 24 hours of the admission ... Second completion should occur 48 hours prior to discharge, but at least 4 hours prior to discharge ... ".

Review on December 5, 2019, of MR4 revealed the patient was admitted to the facility of March 16, 2019, and discharged on March 27, 2019. Further review of MR4 revealed no documentation the Important Message from Medicare was given to the patient at the time of admission.

Review of December 5, 2019, of MR5 revealed the patient awas admitted to the facility on October 28, 2019, and discharged on November 4, 2019. Further review of MR5 revealed no documentation the Important Message from Medicare was given to the patient at the time of discharge.

Review of December 5, 2019, of MR6 revealed the patient was admitted to the facility on October 24, 2019, and discharged on November 11, 2019. Further review of MR6 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review of December 5, 2019, of MR8 revealed the patient was admitted t o the facility on October 4, 2019, and discharged on November 15, 2019. Further review of MR8 revealed no documentation the Important Message from Medicare was given at the time of admission or discharge.

Review on December 5, 2019, of MR10 revealed the patient was admitted to the facility on October 21, 2019, and discharged on October 29, 2019. Further review of MR10 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review of December 5, 2019, of MR11 revealed the patient was admitted to the facility on October 18, 2019, and discharged on October 24, 2019. Further review of MR11 revealed no documentation the Important Message to Medicare was given at the time of admission or discharge.

Review on December 6, 2019, of MR13 revealed the patient was admitted to the facility on October 21, 2019, and discharged on November 6, 2019. Further review of MR13 revealed no documentation the Important Message from Medicare was given at the time of admission or at the time of discharge.

Review on December 6, 2019, of MR14 revealed the patient was admitted to the facility on November 19, 2019, and discharged on November 23, 2019. Further review of MR14 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review on December 6, 2019, of MR15 revealed the patient was admitted to the facility on October 24, 2019, and discharged on November 11, 2019. Further review of MR15 revealed no documentation the Important Message from Medicare was given at the time of admission.

Interview with EMP4 on December 6, 2019 at 2:00 PM Interview with EMP3 on December 6, 2019, at 11:30 AM confirmed the Important Message from Medicare was not documented as indicated in the above medical records.

cross reference with:
482.12 Governing Body
482.13 Patient Rights

Based on review of facility documents, medical records (MR) and staff interview (EMP) it was determined the facility failed to provide written notice to patients that a doctor of medicine or osteopathy were not present in the facility or on-call for the facility, 24 hours per day, seven days per week for 53 of 53 medical records reviewed. (MR1 thru MR53)

Finding s include:

Review on December 3, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff rules and Regulations" approved April 20, 2019, revealed "... 11.0, On-Call - There is a physician possessing skills and knowledge in behavioral health and medical services who is on-call to the Hospital on a 24-hour basis to cover assessments, admissions and emergencies ... The Medical Director shall be administratively responsible for maintaining the Hospital's on-call roster ..."

Review on December 3, 2019, of facility document "Condition of Admission-Inpatient" revised July 2019, revealed no written notification a physician provider would not be present at the facility or on-call 24-hours per day, 7 days a week.

Review on December 6, 2019, of CF9 revealed they were a nurse practioner with a current license to practice.

Review on December 3, 2019, of the on-call calendar dated December 2018 to December 2019 revealed CF9 provided on-call services for the following days: December 21-23, 2018 and December 28-30, 2018; January 25-27, 2019; February 22-24, 2019; March 22-24, 2019 and March 29-31, 2019; April 26-28, 2019; May 24, 2019 to June 2, 2019, 2019; July 19-21, 2019; August 23-25, 2019 and August 30, 2019 to September 1, 2019; September 27-29, 2019; October 25-27, 2019; November 22-24, 2019 and November 29, 2019 to December 1, 2019; December 20-22, 2019.

Interview on December 4, 2019, at 9:50 AM with EMP1 confirmed CF9 was not a physician and provided on-call coverage for the facility.


cross reference with:
482.12 Governing Body
482.13 Patient Rights

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the right to formulate advance directives in three of 14 medical records reviewed. (MR7, MR10, MR15).

Findings include:

Review on December 5, 2019, of facility policy "Advanced Directives," approved February 20, 2019, revealed, " ... Admitting staff will complete the Advance Directives to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulate an Advance Directive. If the patient/legal representative reports and Advance Directive has been formulated the staff will request a copy of the document be provided for verification purposes and to have available in the medical record. If the referring facility has an Advance Directive document they will be requested to provide it if a copy has not accompanied the patient on transfer. If the patient does not have an Advanced Directive, or desires additional information, they will be provided information upon admission. The patient/legal representative shall be requested to sign the Advance Directive form to acknowledge receipt of information regarding Advance Directive."

Review on December 5, 2019, of facility's medical record document that included "Social Services: Emergency/Crisis Planning & Risk Factors" revealed Advance Directives was to be documented by staff with a check mark at one of the following:
"Patient has an Advance Directive (transmit with transition record)
Patient has a health care surrogate (MHPOA, Guardian etc).
Patient is unable to name a surrogate decision maker or provide an advance care plan
Patient refused an advance care plan
Patient has a cultural and/or spiritual believes which preclude a discussion of advance care planning."

Review on December 5, 2019, of MR7 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Review on December 5, 2019, of MR10 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Review on December 5, 2019, of MR15 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Interview with EMP4 on December 5, 2019, at 2:00 PM confirmed the above findings in MR7, MR10, MR15.

cross reference with:
482.12 Governing Body
482.13 Patient Rights

Based on review of facility policy and procedure, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the patient was given the right ot have family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital in five of 14 medical records reviewed (MR6, MR7, MR9, MR13, MR15).

Findings include:

Review on December 5, 2019, of facility policy "Notification of a Family member or Representative," approved February 2019 revealed, " ... The facility will obtain a release of information from the patient upon admission in order to notify the patient's family member or representative and the patient's physician. If the patient states he/she does not want the family member, representative, and/or personal physician notified, the staff member will document this refusal in the chart."

Review on December 5, 2019, of MR6 revealed the patient was admitted to the facility on October 24, 2019. Further review of MR6 revealed no documentation the patient was given the right to have a family member or representative of his or her choice and his or her own physcian notified promptly of his or her admission to the hospital.

Review on December 5, 2019, of MR7 revealed the patient was admitted to the facility on November 22, 2019. Further review of MR7 revealed no documentation the patient was given the right to have a family member or representative of his or her choice notified promptly of their admission to the facility. Continued review of MR7 revealed the physician notification of admission was documented as "pending prior to discharge ... Pt signed ROI (Release of Information)."

Review on December 5, 2019, of MR9 revealed the patient was admitted to the facility on November 15, 2019. Further review of MR9 revealed no documentation the patient was given the right to have a family member or representative of his or her choice or his or her own physician notified promptly of their admission.

Review on December 5, 2019, of MR13 revealed the patient was admitted to the facility on October 21, 2019. Further review of MR14 revealed no documentation the patient was given the right to have his or her own physician notified promptly of their admission.

Review on December 5, 2019, of MR15 revealed the patient was admitted to the facility on October 24, 2019. Further review of MR15 revealed no documentation the patient was given the right to have a family member or representative of his or her choice or his or her own physician notified promptly of their admission.

Interview with EMP4 on December 5, 2019, at 1:30 PM confirmed the "Release of Information" provided to the patient at admission for signature was to send information to the patient's family or representative and the patient's physician at the time of discharge.

Continued interview with EMP4 on December 5, 2019 at 1:30 PM and interview with EMP3 on December 6, 2019, at 11:30 AM confirmed there was no documentation if the patient was given the right to have a family member of representative of his or her choice and/or his or her own physician notified promptly of their admission to the hospital in the above medical records.

cross reference with:
482.12 Governing Body
482.13 Patient Rights

Based on review of facility policy and procedures, review of facility documents, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure their approved policy for Occupancy Health was followed in eight of eight personnel files reviewed for facility health requirements (PF1, PF2, PF3, PF4, PF5, PF6, PF7, PF8).

Findings include:

Review on December 3, 2019, of facility policy and procedures, "Occupancy Health," approved January 2019 revealed, "The primary functions of occupational health for Haven Behavioral Health hospitals are: 1. The health assessment of employees on hire regarding TB status and eligibility for seasonal influenza vaccine ... 2. Establishing the immunity status of employees for MMR, varicella, TDAP, Hepatitis B. Titers or proof of vaccination will be provided for newly hired employees. If an employee chooses to decline a vaccination then document and place in confidential medical personnel file. Federal law requires Hepatitis B vaccination to be offered to all employees providing direct care ... ".

Review on December 3, 2019, of facility document "Employee Tuberculosis Screening," revealed, "Federal law requires ALL EMPLOYEES to have a current 2-Step Tuberculosis Screening upon hire. Further review of the facility document revealed the employee was given the choice to check off one of the following for "Consent":

"- I am a new employee. I consent to receive the PPD Tuberculosis screening.
- I am a new employee. I have a negative chest Xray or negative PPD which will be less than one year old on my first scheduled working day. I will forward these results before my first scheduled working day.-
- I consent to the receive the two-step PPD Tuberculosis Screening.
- I have a history of PPD's and need a chest x-ray for screening."

Review on December 3, 2019, of PF1 revealed the date of hire was October 14, 2019. Further review of the "Employee Tuberculosis Screening" revealed no documentation of PPD#1 of PPD#2 on hire. Further review of PF1 revealed no documentation or delineation of Hepatitis B, TDAP, Varicella or MMR titers or proof of vaccination.

Review on December 3, 2019, of PF2 revealed the date of hire was September 16, 2019. Further review of PF2 revealed no documentation of a 2 Step Tuberculosis Screening on hire.

Review on December 3, 2019, of PF3 revealed the date of hire was October 14, 2019. Further review of PF2 revealed no documentation of PPD#2 on hire, no documentation or declination Hepatitis B, influenza, TDAP, or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF4 revealed the date of hire of was December 10, 2018. Further review of PF4 revealed no documentation of a two-step Tuberculosis Screening on hire. Further review of PF4 revealed no documentation or declination of influenza, MMR or Varicella titers or proof of vaccination.

Review of December 3, 2019, of PF5 revealed the date of hire was December 4, 2018. Further review of PF5 revealed no documentation of PPD#2 on hire. Further review of PF5 revealed no documentation or declination of MMR, TDAP or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF6 revealed the date of hire was October 28, 2019. Further review of PF6 revealed no documentation of PPD#2 Tuberculosis Screening on hire. Further review of PF6 revealed no documentation or declination of MMR TDAP, or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF7 revealed the date of hire was December 14, 2018. Further review of PF7 revealed no documentation or declination of Hepatitis B, TDAP, Varicella or MMR titers or proof of vaccination.

Review of December 3, 2019, of PF8 revealed the date of hire was October 14, 2019. Further review of PF8 revealed no documentation of PPD#2 on hire and no documentation or declination of Hepatitis B, MMR, Varicella or TDAP titers or vaccination.

Interview on December 4, 2019, with EMP3 at 1:15 PM confirmed the above findings for direct care staff in PF1 through PF8.

cross reference with:
482.12 Governing Body
482.13 Patient Rights
482.42(a) Infection Control Officer

Repeat deficency:
Event ID WNWM11 10/11/2018

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to develop distinct performance improvement projects that reflect the scope and complexity of services and operations at the facility (dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services).
Findings include:
A request was made on December 5, 2019, at approximately 10:30 AM for a list of performance improvement projects for dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, nursing services and ambulance services. None provided.
Interview on December 5, 2019, at approximately 12:30 PM with EMP2 confirmed the hospital does not conduct distinct performance projects for dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, nursing services and ambulance services.

cross reference with:
482.12 Governing Body
482.21 Qapi Governing Body, standard tag

Repeat deficency:
Event ID WNWM11 10/11/2018

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) monitoring was performed that reflected the scope of services provided at the facility.

Findings include:

Review on December 5, 2019, of facility document "Haven Behavioral Hospital of Philadelphia Performance Improvement Plan" approved September 2019, revealed "Responsibility- The Governing Board has the ultimate authority and responsibility for adopting an organization-wide plan to assess and improve the quality of care provided ..."

On December 5, 2019, at approximately 10:00 AM a request was made to EMP2 for a list of Quality Assessment and Performance Improvement (PI) projects approved by the Governing Board that provided information for the reason PI projects were selected, the scope, frequency and method of data collection, and analysis of collected data. None provided.

Interview on December 5, 2019, at approximately 11:50 AM with EMP2 confirmed there was no documentation Performance Improvement projects were selected and approved by the Governing Board to assess and improve the quality of care at the facility.


cross reference with:
482.12 Governing Body
(482.21(a),(b)(1),(b)(2)(i),(b)(3) Data Collection and Anlaysis

Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure the Director of Nursing was qualified to manage and direct nursing services at the facility. (PF21)

Findings include:

Review on December 4, 2019, of facility document "Haven Behavioral Healthcare, Job Description, Director of Nursing," reviewed May 2017, revealed "... Qualifications: Education- Bachelor's Degree in Nursing from an accredited program. Master's preferred ..."

Review on December 4, 2019, of PF21 documentation revealed "Education Reference: Completed October 10, 2019," revealed "Major-Nursing, Level attained- Associates in Applied Sciences ..."

Interview on December 4, 2019, at 2:00 PM with EMP1 confirmed the employee in CF21 was recently hired in October 2019 and confirmed CF21 did not possess the educational requirements for the Director of Nursing position.

cross reference with:
482.12 Governing Body

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their own policy to administer scheduled drugs and biologicals according to the medication orders of a practioner for one of one medical record reviewed (MR54).

Findings include:

Review on December 5, 2019 of facility policy, " Medication, Standard Administration Times," revised October, 2019, revealed, "... Definitions: ... C. "Scheduled" medication orders ... Medications such as Insulin, ... must be administered within 30 minutes of scheduled time (1/2 hour before to 1/2 hour after the scheduled time) ... ."

Review of MR54 revealed a physician order for Insulin Lispro on December 5, 2019 scheduled to be administered at 8:00 AM. Further review of MR54 revealed Insulin Lispro was administered on December 5, 2019 at 8:45 AM.

Interview on December 5, 2019 at 1 PM with EMP3 confirmed facility failed to follow their own policy for scheduled administration of Insulin Lispro to patient related to MR54.

cross reference with:
0386 482.23(b)(2) Organization of Nursing Services

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to properly store medical records from fire, water damage and other threats.

Findings include:

Review on December 4, 2019, of facility policy "Confidentiality and Security of Medical Records," approved December 2019, revealed "... Record Security: In the event of a fire-assigned staff will immediately go to the medical records storage area with a fire extinguisher ... Medical records is [sic] protected by a fully operational sprinkler system ... In the event of probable water damage, if there is time, staff will remove charts on the lower shelves moving them to higher level for safety ..."

Observation on December 4, 2019, at 10:45 AM of the medical record storage area revealed a locked room that contained 7- 12 ft. long x 8 ft. high, open-metal shelves and ceiling mounted fire suppression sprinklers. Further observation revealed the open metal shelving contained paper medical records for patients that received treatment at the facility for the prior 24 months.

Interview on December 4, 2019, at 11:00 AM with EMP5 confirmed the metal shelving did not provide protection for stored medical records in the event the fire suppression sprinklers were activated.

Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure medical records were completed within 30 days of discharge for 33 of 33 medical records reviewed. (MR19 thru MR53)

Findings include:


Review on December 4, 2019, of facility policy "Deficiencies and Delinquencies," approved November 2019, revealed "Purpose: to clearly define deficiency, delinquency and a complete medical record ... Definition of Delinquency-A medical record is considered delinquent when 1 or more required elements have not been competed and in the medical record within established timeframes ... It is required medical records be closed no later than 30 days after discharge ..."


Review on December 4, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff Rules and Regulations," approved April 2019, revealed
"... 7.14 Completion of Medical Records - all discharge summaries and other medical record documentation shall be completed within (15) days following the patient ' s discharge. Incomplete records exceeding (15) fifteen days following discharge will be considered delinquent ..."

A request was made on December 4, 2019, at 10:50 AM for the Medical Records Committee Meeting Minutes. None provided.

Review on December 6, 2019 of facility delinquent medical records as of December 6, 2019, revealed:

20 Medical records were 31-59 days delinquent
12 Medical records were 60-89 days delinquent
1 Medical record were 90-119 days delinquent

Interview with EMP5 on December 4, 2019, at approximately 11:05 AM, confirmed the above listed delinquent medical records.
cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to have Utilization Review Committee make a periodic review for current inpatient receiving hospital services during a continuous period of extended duration.

Findings include:

Review on December 4, 2019 of facility's, "Utilization Review Committee Minutes," dated 12/20/18, 2/12/19, 3/13/19, 6/28/19 and 7/17/19 , revealed, "... no documented evidence of review of current inpatient receiving hospital services during a continuous period of extended duration.

Review on December 4, 2019 of facility's, "Utilization Management Plan," revised June 2016, revealed, no specification for periodic review of extended stay inpatient cases.

Request was made on December 4, 2019 to EMP6 for documented evidence that the Utilization Review Committee periodically reviewed extended stay cases. None provided.

Interview with EMP6 on December 5, 2019 between 10:11 AM and 10:21 AM confirmed facility failed to have the Utilization Review Committee make a periodic review for current inpatient receiving hospital services during a continuous period of extended duration. Further confirmed the Utilization Management Plan does not specify periodic review of extended stay inpatient cases.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to have UR (Utilization Review) committee review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

Findings include:

Review on December 4, 2019 of facility's, " Plan for Service," revised May 2017, revealed, "... Description of Clinical Services ... Consultation and Referrals, Dental Services, Diagnostic Testing and Procedures, Dietary Services, Emergency Services, Medical Services Nursing Services, Pharmacotherapy, Physical/Occupational Therapy, Psychological Services, Social Services and Speech, Language, Hearing ... ."

Review on December 4, 2019 of facility's, "Utilization Management Plan," revised June 2016, revealed, " ... The purposes of the Utilization Management Plan are: 1. To assure appropriate utilization of all services provided by the hospital ... Scope of Service The Utilization Management Department and Utilization Review Committee evaluate and monitor services to patients provided by medical and other professional staff ... ."

Request was made on December 4, 2019 to EMP6 for documented evidence that the Utilization Review Committee reviewed professional services provided, to determine medical necessity and to promote the most efficient use of available services. None provided.

Interview with EMP6 on December 5, 2019 between 10:11 AM and 10:21 AM confirmed facility failed to have the Utilization Review Committee review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag
0657 482.30(e) Extended Stay Review

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on November 07, 2019. Further details are outlined in that Division of Life Safety Survey Report.

Based on review of facility documents and interview with staff it was determined the facility failed to ensure the employee designated as the infection control officer was qualified, through specialized training or certification. (PF21)

Findings include:

Review on December 4, 2019, of facility document "Haven Behavioral Health Infection Prevention and Control Plan, 2019" revealed no documentation for educational requirements or specialized certification for the designated infection control officer.

Review on December 4, 2019, of facility document "Infection Prevention and Control Officer Appointment Letter" approved April 2019, revealed no documentation specialized training or certification were required to carry out the responsibilities of the Infection Control Officer.

Review on December 4, 2019, of PF21 revealed no documentation the employee possessed any specialized training or certification to oversee the infection control program.

Interview on December 4, 2019, with EMP1 at 1:00 PM confirmed PF21 does not have any specialized training or certification to meet the requirements of the Infection Control Officer.

cross reference with:
482.12 Governing Body

Repeat deficency:
Event ID WNWM11 10/11/2018

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to develop a system for controlling infections and communicable diseases of patients and personnel, as evidenced by not having an established process to place a patient in isolation precautions for one of one medical records reviewed (MR55) .

Findings include:

Review on December 3, 2019 of facility's, "Precaution Categories-Standard, Droplet, Contact, Airborne," revised 12/2016, revealed, " ... Contact Precautions contact transmission occurs when an infected person transfers microorganisms to another person. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms ... These illnesses include: ... skin infections that are highly contagious: diphtheria, herpes, impetigo, noncontained abscesses, cellulitis or decubiti, pediculosis, scabies, zoster ..."

Review on December 5, 2019 of MR55's, "History and Physical," dated October 25, 2019, revealed this patient, "... comes in on oral antibiotics for the right thumb infection ... Assessment: Acute: ... 2. Acute Cellulitis of the right hand after an injury. He is on Bactrim until October 28th ... ."

Review on December 5, 2019 of MR55's, "Nursing Reassessment," dated October 25, 2019 at 1720 revealed, " Received lab results from Dr. ... office with confirmation of +staph infection in right thumb. Patient is currently on Bactrim. PA [Physician Assistant] notified. Continue Bactrim full course ... ." Further revealed no documented evidence of patient placement on isolation precautions.

Request was made on December 5, 2019 to EMP3 for policy on how isolation precautions would be requested and implemented for patient in MR55. None provided.

Interview with EMP3 on December 5, 2019 at approximately 2:30 PM confirmed facility failed to have a process to request and implement isolation precautions.

cross reference with:
482.12 Governing Body
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.42(a)(1) Infection Control Officer(s)

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to reassess its discharge planning process on an on-going basis.

Findings include:

Review on December 5, 2019, of facility document "Haven Behavioral Hospital of Philadelphia Performance Improvement Plan" approved September 2019, revealed "Responsibility- The Governing Board has the ultimate authority and responsibility for adopting an organization-wide plan to assess and improve the quality of care provided ..."

Request was made on December 6, 2019 to EMP2 for documented evidence that the facility reassesses its discharge planning process on an on-going basis. None provided.

Interview with EMP2 on December 6, 2019 at approximately 10:30 AM confirmed facility failed to reassess its discharge planning process on an on-going basis.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag
482.23(b)(2) Organization of Nursing Services

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

I. Ensure that the Psychosocial Assessments included clearly identified social workers' role in treatment (B108) and The Psychiatric Assessment included documentation of patients' personal assets in descriptive fashion that can be utilized in treatment planning (B117).

II. Ensure that the Master Treatment Plans (MTPs) are individualized and comprehensive (B118), included, patient specific problem statements (B119), measurable goals (B121), patient problem specific interventions (B122), and identified staff responsible for providing the interventions (B123).

III. Ensure that treatment and progress notes are documented by social work staff (B124).

Based on document review and staff interview, the facility failed to ensure that the Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) included patient specific, anticipated Social Work roles in treatment. The identified recommendations were generic and similar to many patients. As a result, critical and professional patient specific, psychosocial information necessary for informed treatment planning decisions was not available to the treatment team.

Findings are:

A. Record Review

I. Patient A1 was admitted with a diagnosis of "Schizoaffective disorder, depressed type" on 9/29/19. The Psychosocial Assessment completed on 10/1/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were "encourage pt. to engage in milieu activities ..., encourage compliance with medications ..., encourage pt. to accomplish treatment plan goals ..., encourage pt. engage in securing aftercare appointments ...."

II. Patient A2 was admitted with a diagnosis of "unspecified psychotic disorder" on 10/23/19. The Psychosocial Assessment completed on 10/24/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "encourage pt. to engage in milieu activities ..., encourage to comply with medications ..., encourage pt. to accomplish treatment plan goals ..., encourage pt. engage in securing aftercare appointments..."

III. Patient A3 was admitted with a diagnosis of "Schizoaffective disorder, bipolar type with acute psychosis" on 11/27/19. The Psychosocial Assessment completed on 11/27/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "encourage pt. to engage in all milieu activities ..., encourage compliance with medications ..., encourage pt. to accomplish treatment plan goals ..., encourage pt. engage in securing aftercare appointments..."

IV. Patient A4 was admitted diagnosis of "Schizoaffective disorder, bipolar type with acute psychosis" on 11/28/19. The Psychosocial Assessment completed on 11/29/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "[patient name] will attend and engage in group sessions and milieu activities ..., [patient name] will attend at least 1 activity therapy or social work processing group per day.., [pt. name] will be meals and medications compliant ..., [pt. name] will perform ADL's for 3 consecutive days ..." These are all staff's expectations for the patient to do rather than staff interventions to assist the patient in improving their mental health.

V. Patient A5 was admitted with a diagnosis of "Paranoid schizophrenia" on 9/29/19. The Psychosocial Assessment completed on 10/1/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "encourage pt. to engage in milieu ..., encourage compliance with medications ..., encourage pt. to accomplish treatment plan goals ..., encourage pt. engage in securing aftercare appointments..."

VI. Patient A6 was admitted with a diagnosis of "Unspecified psychosis" on 11/11/19. The Psychosocial Assessment completed on 11/12/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "[pt. name] to be medication and meal compliant ..., [Pt. name] attend all his/her assigned groups... Social worker will meet with patient one-on-one to assist his/her MH (Mental Health) symptoms and encourage compliance with medication and treatment..."

VII. Patient A7 was admitted with a diagnosis of "Schizophrenia; neurocognitive disorder; Alzheimer type" on 11/28/19. The Psychosocial Assessment completed on 11/30/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "[pt.name] will attend and engage in milieu ..., [pt. name] will attend at least one activity therapy or social work processing group per day ..., [pt. name] will be meal and medication compliance ..."

VIII. Patient A8 was admitted diagnosis of "Bipolar disorder, unspecified type" on 11/30/19. The Psychosocial Assessment completed on 12/2/19 did not identify anticipated roles for social work staff in formulating and/or identifying interventions for inpatient treatment. The identified recommendations were, "will encourage [pt. name] to admit that their actions were suicidal and homicidal in nature ..., will encourage [pt. name] to be completely meal and med compliant ..., will encourage [pt. name] to attend all assigned groups ..."

B. Staff interview:

In a meeting with the Director of Social Services on 12/10/19 at 3:00p.m., the above deficiencies were reviewed and she did not dispute the findings.

Based on medical record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patients' personal attributes in a descriptive fashion for five (5) of eight (8) active sample patients (A1, A2, A5, A6 and A8). This failure to identify patient's personal assets impairs the treatment team's ability to choose treatment modalities that utilizes a patient's assets in therapy.

Findings include:

A. Record Review

I. Psychiatric evaluation (date in parenthesis) of patient A1 (9/30/19) had, "The patient has stable housing and staff supervision." as patient's assets.

II. Psychiatric evaluation (date in parenthesis) of patient A2 (10/23/19) had, " The patient has stable housing." as Patient Assets.

III. Psychiatric evaluation (date in parenthesis) of patients' A5 (10/1/19) had, "Does not give any strength."

IV. Psychiatric evaluation of patient A6, dated 11/12/19 had, "[He/she] reported [his/her] strength as [his/her] wife and family."

V. Psychiatric evaluation for patient A8, dated 12/1/19 had, "Strength: Family supportive."

B. Interview

In a meeting and review of the above deficiencies on 12/11/19 at 10:30 a.m., the Medical Director stated that it was his understanding, "We have to write what the patient states as their strengths."

Based on medical record review, staff interview and policy review the facility failed to develop treatment plans with all elements critical to effective treatment planning and implementation in eight (8) of eight (8) records reviewed (Patients A1, A2, A3, A4, A5, A6, A7 and A8). In two (2) of eight (8) records (Patients A4 and A7), the problems identified were presented in diagnostic terminology or initials. The majority of the goals and interventions in all Master Treatment Plans (MTP's) were the same regardless of the stated problem. Eight (8) of eight (8) patients' goals were statements of treatment compliance, including attendance at programming activities rather than outcome behaviors reflecting evidence that the identified problem had been reduced or resolved. Staff interventions for eight (8) of eight (8) patients were generic staff role function statements or the identified modality failed to include a focus for treatment. This approach to treatment failed to provide individualized plans to guide staff in the implementation and evaluation of the treatment provided and revisions of the plans based on the individual patient's responses to treatment.

Findings include:

A. Record Review

I. Review of MTP's revealed failure to identify individualized patient goals based on the patient's needs for eight (8) of eight (8) sample patients (treatment plan dates in parenthesis): A1 (10/01/19); A2 (10/25/19); A3 (11/28/19); A4 (11/30/19); A5 (10/02/19); A6 (11/14/19); A7 (11/29/19) and A8 (11/03/19). The majority of short-term goals (Objectives) were generic statements addressing medication compliance and/or attendance in therapeutic milieu activities. These goals were treatment compliance statements rather than behavioral statements that were observable and measureable to allow staff to determine if the stated problem had been reduced or resolved (Refer to B121).

II. In all eight (8) MTP's the majority of staff interventions for clinical disciplines were somewhat similar to all patients, generic role function statements or a list of modalities without focus of treatment rather than interventions aimed at assisting the patients to address the identified problem and lead to stabilization or recovery of health status (Refer to B122).

III. In all eight (8) MTP's the majority of interventions did not identify a particular staff person responsible for providing the modality. Instead the responsibility was assigned to the discipline (Refer to B123).

B. Staff Interview:

During an interview with the Medical Director and the Director of Social Work on 12/10/19 at 12:10 p.m., the treatment plan goals and interventions were reviewed. Both Directors agreed with the findings. The Director of Social Work stated, "We have already identified we have problems with our treatment plans and training has been scheduled with Corporate staff next month."

Based upon medical record review, staff interview and policy review the facility failed to provide a treatment plan that identified and precisely described problem behaviors. Instead, problems were presented with diagnostic terminology or initials, in two (2) of eight (8) treatment plans (Patients A4, A7). This results in treatment plans not being individualized for the patient and therefore could either be misinterpreted or misunderstood by the staff and patient.

Findings include:

A. Medical record review

I. Patient A7 (admitted 11/28/19; Master Treatment Plan (MTP) 11/29/19)
- Problem statement was written as: "AH/SI" (auditory hallucinations/suicidal ideations). No description written to define the auditory hallucinations or the degree of suicidal ideations.

II.. Patient A4 (admitted 11/28/19; MTP 11/30/19)
- Problem statement written was: "+ audio hallucinations." No description written to define the auditory hallucinations.

B. Staff Interview

The Director of Social Work, in the presence of the Medical Director and the Quality/Risk Management Manager, on 12/10/19 at 12:10 p.m., stated that the findings on Patient A7 and A4 related to the problem statements were inaccurate, "They do not clearly describe to the patient or members of the team what is the identified problem."

C. Policy Review

Facility Policy, titled "Treatment Plan," last revised 03/17 stated: "The problems are documented in descriptive, behavioral terms."

Based upon medical record review, staff interview and policy review the facility failed to delineate on the Master Treatment Plan (MTP) specific measurable, behavioral short term patient centered goals, based on the individual patient needs and/or problem behaviors requiring hospitalization for eight (8) of eight (8) sampled patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). In addition, many of the short-term goals written were generic and similar from one treatment plan to another. This failure hinders the ability to measure change in the patient as a result of the treatment interventions and may prolong hospital stays beyond the resolution of the behavior(s) requiring admission.

Findings include:

A. Medical Record Review:

I. Patient A1, admitted 09/29/19 with Schizoaffective Disorder Depressed Type. (S/he) thought about putting a knife/razor to throat but did not. However, described feeling the sensation of the razor. The patient's MTP, dated 10/01/19, stated the following short term goals: "[patient name] will be completely meal and med compliant on the unit by day seven (7) as to secure the efficacy and effectiveness of medication; will attend all assigned groups on the unit as to promote ability to interact with others with decreased visual hallucinations and suicidal ideation to promote behavioral stability by day seven (7); will meet with Social Worker and Physician alongside other facility staff to secure outpatient services and housing upon discharge."

These goals were unrealistic for a patient with a severe disability from psychosis. Subsequent treatment plan updates completed on 10/08/19, 10/15/19, 10/22/19, 10/29/19, 11/4/19, 11/22/19, 11/19/19, 11/26/19 and 12/3/19 indicated none of the goals had been achieved, but the plan had not been revised to identify new or more realistic, measurable goals for this patient.

II. Patient A2, admitted 10/22/19 with Paranoid Schizophrenia. (S/he) presented with grandiose delusions, stating (S/he) had created Oprah Winfrey's magazine. Also expressing suspicion and paranoia regarding the shelter (where patient lived) owner. Disorganized and tangential thoughts present on admission." The patient's MTP, dated 10/25/19, stated the following short term goals: "will fully engage in all therapeutic milieu activities by day seven (7); will comply with prescribed medication regimen by day seven (7); will attempt to accomplish assorted treatment plan goals by day seven (7); and will engage in securing all aftercare appointments recommended by treatment team."

These goals were unrealistic for a patient with a severe disability from psychosis. Subsequent treatment plan updates completed on 10/11/19, 10/18/19, 10/25/19, 11/1/19, 11/8/19, 11/22/19, 11/29/19 and 12/6/19 indicated none of the goals had been achieved, but the plan had not been revised to identify new or more realistic, measurable goals for this patient.

III. Patient A3, admitted 11/27/19, with Bipolar Type Disorder, Psychosis, Schizoaffective Disorder. (S/he) was admitted with delusional thoughts, believing that (s/he) was the mother Mary and was pregnant. The patient's MTP, dated 11/28/19, stated the following short term goals: "[patient name] will be completely meal and med compliant on the unit as to secure the efficacy of and to assure the effectiveness of medication by day seven (7); the Social Work will meet with patient weekly for one-to-one (1:1) sessions to assist the patient with cognitive therapeutic approaches to help identify problematic beliefs to replace with alternative, more adaptive thinking."

These goals were generic staff expectations and/or were written in terms of what staff would accomplish.

IV. Patient A4, admitted 11/28/19, with Schizophrenia. (S/he) was admitted with an altered mental status, auditory and visual hallucinations and mood lability. At times was also catatonic.

MTP, dated 11/30/19, stated the following short term goals: "[patient name] will be free of audio-hallucinations for three (3) consecutive days; will attend at least two (2) groups per day to help eliminate hallucinations and agitation; will be meal and med compliant by day three (3) and express if needed any concerns with medications with psychiatrist."

These goals were unrealistic for a patient with a severe disability related to psychosis.

V. Patient A5, admitted 09/29/19 with Paranoid Schizophrenia. (S/he) believed that the staff, "were vampires trying to drink his/her blood and staff were trying to poison him/her." Patient was also non-compliant with medication because "medications come from evil." The patient's MTP, dated 10/02/19, stated the following short term goals: "[patient name] will fully engage in all therapeutic milieu activities by day seven (7); will comply with prescribed medication regimen by day seven (7); will attempt to accomplish assorted treatment plan goals by day seven (7); and will engage in securing all aftercare appointments recommended by treatment team."

These goals were unrealistic and for a patient with a severe disability from psychosis. Subsequent treatment plan updates completed on 10/11/19, 10/18/19, 10/25/19, 11/1/19, 11/8/19, 11/22/19, 11/29/19 and 12/6/19 indicated none of the goals had been achieved, but the plan had not been revised to identify new or more realistic, measurable goals for this patient.

VI. Patient A6, admitted 11/11/19 with unspecified psychosis, rule out major depressive disorder, recurrent, severe, with psychosis. (S/he) was having suicidal thoughts and threatening to kill self; refusing to take medication, refusing to eat or drink anything. Spouse reported auditory hallucinations telling him/her to kill self via drowning self in a creek. The patient's MTP, dated 11/14/19, state the following short term goals: "will develop positive coping skills to manage depression via one-on-one (1:1) counseling and attending at least two (2) assigned groups daily by day seven (7); and [patient name] will present with suicidal ideation and be better equipped to manage depressive triggers by day seven (7)."

These goals were unrealistic for a patient with a severe disability from psychosis and depression. Subsequent treatment plan updates completed on 11/21/19, 11/28/19 and 12/5/19 indicated slight improvement in symptoms of depression and anxiety in the section titled "progress/lack of progress toward treatment goals" but no plan revisions to identify new or more realistic, measurable goals for this patient.

VII. Patient A7, admitted 11/28/19 with Schizophrenia; Neurocognitive Disorder Alzheimer type. (S/he) was experiencing visual hallucinations of cows being everywhere, experiencing depression and confusion, stating (s/he) wanted to be dead but did not have a plan. The patient's MTP, dated 11/29/19, stated the following short term goals: "[patient name] will be medication and meal compliant by day seven (7); will maximize the capacity for independent functioning in daily ADL's (activities of daily living); will participate in two-to-three (2-3) therapeutic goals on the unit to practice reality based thinking and increase socialization with others; and will reframe from eloping to maintain safety and comply with treatment recommendations."

These goals were unrealistic for a patient with a severe disability from psychosis and dementia.

VIII. Patient A8, admitted 11/30/19, with Bipolar Disorder, unspecified; unspecified Anxiety Disorder. (S/he) was admitted after cutting throat and a homicide attack against spouse. The patient's MTP, dated 12/3/19, stated the following short term goals: "[patient name] must be completely meal and med compliant on the unit as to secure the efficacy of and to assure the effectiveness of medication by day seven (7); must attend all assigned therapeutic groups to promote behavioral stability by day seven (7)."

These goals were generic and non-specific to this patient's identified condition.

IX. Four (4) patients (A3, A5, A6 and A7) had co-morbid active medical conditions identified as a part of their MTP. With these co-morbid conditions, a pre-printed treatment plan forms are utilized with the following same three (3) short term goals/patient objectives in spite of different medical conditions identified on the plans: "the patient will provide information to the treatment team regarding all current and past medical problems; the patient will cooperate with treatment and evaluation recommendations regarding current medical problems; and the patient will demonstrate an understanding of his/her illness(es) and the need for medication(s), and plans for after discharge follow-up care for his/her medical problems."

These pre-printed goals were generic and non-specific for all medical problems identified on these plans.

B. Staff Interview

During an interview with the Medical Director and the Director of Social Work, on 12/10/19 at 12:10 p.m., when the treatment plans for patients A6 and A7 were reviewed, they verified that the short-term goals as written were not measurable in terms of what the patients were to accomplish. The Medical Director stated, "I understand they need to be more specific and measurable and written in individual behavioral terms."

C. Policy Review

Facility policy titled, "Treatment Plan" last revised 03/17, section C states: "the goal is expressed in measurable, achievable, time framed and appropriate terms, given the patient's diagnosis, cognitive level of function and condition."

Based on medical record review, staff interviews and policy review the facility failed to develop treatment interventions based on the individual needs of the patients for 8 of 8 patients in the sample (A1, 2, A3, A4, A5, A6, A7 and A8). The interventions included were generic and frequently reflected basic job responsibilities of the team members. This failure results in staff being unable to provide direction, consistent approaches and focused treatment for patients' identified problems.

Findings include:

A. Medical Record Review

I. Patient A1, admitted 09/29/19 with Schizoaffective Disorder Depressed Type. (S/he) thought about putting a knife/razor to throat but did not. However, described feeling the sensation of the razor. The patient's MTP, dated 10/01/19, stated the following interventions:

a. "Psychiatrist will meet with patient daily to assess mood and mental status; will prescribe medication that will assist with suicidal ideation alongside psychosis; and will educate on disease and the efficacy of medication."

b. "Social Worker will encourage patient to be completely meal and med compliant on the unit as to secure the efficacy and the effectiveness of medication; will encourage to attend all assigned groups as to promote ability to interact with others in current cognitive state and to promote behavioral stability; will secure safe housing upon discharge from Haven Hospital; and will assess, evaluate and treat as to determine and to meet the most appropriate discharge planning needs."

c. "RN will administer patient's medications and encourage patient to participate in the milieu on the unit as to promote behavioral stability."

II. Patient A2, admitted 10/22/19 with Paranoid Schizophrenia. (S/he) presented with grandiose delusions, stating (S/he) had created Oprah Winfrey's magazine. Also expressing suspicion and paranoia regarding the shelter (where patient lived) owner. Disorganized and tangential thoughts present on admission." The patient's MTP, dated 10/25/19, stated the following interventions:

a. "Psychiatrist will meet with patient daily to assess mood and mental status; will prescribe medication that will assist patient with psychotic symptoms; and will educate patient on disease and the efficacy of medication."

b. "Social Worker will encourage patient to be completely meal and med compliant on the unit as to secure efficacy of and to assure the effectiveness of medication. Social Worker will encourage patient to attend all assigned groups to promote ability to interact with others in current cognitive state and to promote behavioral stability."

c. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to promote behavioral stability."

III. Patient A3, admitted 11/27/19, with Bipolar Type Disorder, Psychosis, Schizoaffective Disorder. (S/he) was admitted with delusional thoughts, believing that (s/he) was the mother Mary and was pregnant. The patient's MTP, dated 11/28/19, stated the following interventions:

a. "Psychiatrist will adjust medication and educate patient on side effects and length of time for meds to properly take effect; and will assess patient daily."

b. "Social work will meet with patient to assess, two times per week; and will meet with patient to discuss unrealistic thoughts and delusional beliefs and engage patient in reality oriented conversation."

v. "Nursing will give patient prescribed meds daily; will educate patient weekly on meds effects and importance of taking meds as it relates to paranoid delusions; and will assess patient daily regarding problems."

IV. Patient A4, admitted 11/28/19, with Schizophrenia. (S/he) was admitted with an altered mental status, auditory and visual hallucinations and mood lability. At times was also catatonic. MTP, dated 11/30/19, stated the following interventions:

a. "Psychiatrist to meet with patient daily to assess, evaluate, prescribe and titrate medications as required."

b. "Social Worker will meet with patient at least two times per week for presence of agitation and auditory hallucinations; will meet with patient to determine triggers and promotes skills to deal with auditory hallucination triggers twice weekly."

c. "RN will administer, assess and evaluate the patient for medication efficacy and any adverse symptoms as required."

d. "Activities Therapy will educate patient with coping skills to ensure functioning in the community post discharge."

V. Patient A5, admitted 09/29/19 with Paranoid Schizophrenia. (S/he) believed that the staff, "were vampires trying to drink his/her blood and staff were trying to poison him/her." Patient was also non-compliant with medication because "medications come from evil." Additionally, this patient had the following co-morbid active medical problems identified: hypertension; hypothyroid; dyslipidemia and obesity. The patient's MTP, dated 10/02/19, stated the following interventions:

a. "Psychiatrist will assess and evaluate patient's psychosis and will treat and adjust antipsychotics and mood stabilizers accordingly."

b. "MSW, LSW will encourage patient to fully engage in all therapeutic milieu activities; will encourage patient to fully accomplish all treatment plan goals; and will encourage to engage in securing all aftercare appointments recommended by Haven Hospital treatment team."

c. "RN will administer patient's medications and encourage to participate in the milieu on the unit as to promote behavioral stability."

For the medical conditions (Hypertension, Hypothyroid, Dyslipidemia, Obesity) listed the following generic preprinted interventions: "nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education, and medication education in order to manage active medical problem." These interventions, were globally applied to each of the diagnoses listed, therefore not individualized to any of the identified medical problems.

VI. Patient A6, admitted 11/11/19 with unspecified psychosis, rule out major depressive disorder, recurrent, severe, with psychosis. (S/he) was having suicidal thoughts and threatening to kill self; refusing to take medication, refusing to eat or drink anything. Spouse reported auditory hallucinations telling him/her to kill self via drowning self in a creek. Additionally, this patient had the following co-morbid active medical problems identified: fall risk and pressure ulcer. The patient's MTP, dated 11/14/19, state the following interventions:

a. "Psychiatrist to assess and evaluate patient's depressive symptoms and suicidal thoughts; and will treat and adjust mood stabilizers and antidepressants appropriately."

b. "MSW, LSW recommends that patient be completely medication and meal compliant to assure the efficacy of medication and gain energy and weight; recommends that patient attend all of (his/her) assigned groups so (s/he) can socialize with peers and learn therapeutic techniques."

c. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to diminish depressive symptoms and to promote behavioral stability."

For the medical conditions (Hyponatremia hx, alcohol abuse hx., Left renal mass) listed the following similar generic preprinted interventions: "nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem." These interventions, were globally applied to each of the diagnoses listed, therefore not individualized to any of the identified medical problems.

VII. Patient A7, admitted 11/28/19 with Schizophrenia; Neurocognitive Disorder Alzheimer type. (S/he) was experiencing visual hallucinations of cows being everywhere, experiencing depression and confusion, stating (s/he) wanted to be dead but did not have a plan. Additionally, this patient had the following co-morbid active medical problems identified: HTN (hypertension); hyperthyroidism; GERD (gastric-esophageal reflux disorder); and high cholesterol. The patient's MTP, dated 11/29/19, stated the following interventions:

a. "Psychiatrist will adjust medication and educate patient on side effects and length of time for meds to properly take effect; and will assess patient daily."

b. "Social Worker will meet with patient to assess two times per week; and will discuss substance abuse/dependency and engage patient in a recovery plan."

c. "Nursing will give patient prescribed meds daily; will educate patient weekly on meds effects and importance of taking meds as it relates to paranoid delusions; and will assess patient daily regarding problems."

For the medical conditions (listed in a column, HTN, Hyperthyroidism, GERD, High Cholesterol) listed the following generic preprinted interventions: "nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem." These interventions, were globally applied to each of the diagnoses listed, therefore not individualized to any of the identified medical problems.

VIII. Patient A8, admitted 11/30/19, with Bipolar Disorder, unspecified; unspecified Anxiety Disorder. (S/he) was admitted after cutting throat and a homicide attack against spouse. The patient's MTP, dated 12/3/19, stated the following interventions:

a. "Psychiatrist will assess and evaluate patient's suicidal ideation and homicidal ideation and/or triggers and will adjust antipsychotics and mood stabilizers accordingly."

b. "Social Worker will meet with patient to assess two times per week; MSW, LSW will encourage patient to admit that (s/he) actions were suicidal and homicidal in nature and not just minimize them as attention seeking gestures; will encourage patient to be completely meal and med compliant on the unit as to secure efficacy of and to assure the effectiveness of medication; will encourage patient to attend all assigned therapeutic groups and to promote behavioral stability; and will assist and counsel patient regarding anger, suicidal ideation and homicidal ideation."

c. "RN will administer patient medication and encourage to participate in the milieu on the unit as to stabilize mood and to promote overall behavioral stability."

B. Staff Interview

I. On 12/10/19, at 3:30 p.m. when the surveyor reviewed the treatment plan for Patient A7 with the Director of Social Work, she stated, "there is no responsible social worker identified on the form." She further stated, "I understand what you are saying about the interventions being more job duties than therapy driven actions. We have already identified problems with our treatment plans and will be having training from Corporate next month. I don't disagree with you; this will only help us to improve."

II. The Director of Nursing, on 12/10/19 at 2:15 p.m., reviewed the treatment plans for patients A4, A6 and A7 and stated, "You are correct the treatment interventions are generic, role responsibilities related to medications. They do not specifically identify what the nurse will do in providing individual care to these patients."

C. Policy Review

I. Facility Policy, titled "Treatment Plan," last revised 03/17, section H states: "The interventions shall be highly individualized, reasonable and necessary to improve the condition that necessitated the hospitalization. Such interventions form the basis of "active treatment."

II. Facility Form, titled "Multidisciplinary Master Treatment Plan," updated 2/27/18 section titled "Multidisciplinary Interventions," provides the following instructions to staff to include: type (modality)/frequency/duration and purpose.

Based on medical record review, staff interview and policy review the facility failed to ensure that the staff member responsible for each intervention was specifically identified in eight (8) of eight (8) treatment plans (Patients A1, A2, A3, A4, A5, A6, A7 and A8). Instead, the Master Treatment Plan identified the staff discipline as the responsible party. This practice results in the facility's inability to monitor staff accountability for specific modalities.

Findings include:

A. Record Review

I. Patient A1 (admitted 09/29/19; MTP 10/01/19)

a. "RN will administer patient's medications and encourage patient to participate in the milieu on the unit as to promote behavioral stability."
Discipline: Team RN

II. Patient A5 (admitted 09/29/19; MTP 10/02/19)

a. "RN will administer patient's medications and encourage to participate in the milieu on the unit as to promote behavioral stability."
Discipline: Team RN

b. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."
Discipline: Nursing

III. Patient A2 (admitted 10/22/19; MTP 10/25/19)

a. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to promote behavioral stability."
Discipline: Team RN

IV. Patient A6 (admitted 11/11/19; MTP 11/14/19)

a. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to diminish depressive symptoms and to promote behavioral stability."
Discipline: Team RN

b. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."
Discipline: Nursing

V. Patient A3 (admitted 11/27/19; MTP 11/28/19)

a. "Social work will meet with patient to assess, two times per week; and will meet with patient to discuss unrealistic thoughts and delusional beliefs and engage patient in reality oriented conversation."
Discipline: Social Work

b. "Activity therapist will assess patient for appropriate groups and assess patient daily. If patient does not come to group alternative programming will be offered on an as needed basis."
Discipline: Activity Therapist

VI. Patient A7 (admitted 11/28/19; MTP 11/29/19)

a. "Social Worker will meet with patient to assess two times per week; and will discuss substance abuse/dependency and engage patient in a recovery plan."
Discipline: Social Work

b. "Nursing will give patient prescribed meds daily; will educate patient weekly on meds effects and importance of taking meds as it relates to paranoid delusions; and will assess patient daily regarding problems."
Discipline: Team RN

c. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."
Discipline: Nursing

d. "Activity therapist will assess patient for appropriate groups and offer aromatherapy to assist with calming/relaxation; if patient does not come to group alternative programming will be offered on an as needed basis."
Discipline: Activity Therapist

VII. Patient A4 (admitted 11/28/19; MTP 11/30/19)

a. "Social Worker will meet with patient at least two (2) times per week for presence of agitation and auditory hallucinations; will meet with patient to determine triggers and promotes skills to deal with auditory hallucination triggers twice weekly."
Discipline: Social Work

b. "RN will administer, assess and evaluate the patient for medication efficacy and any adverse symptoms as required."
Discipline: Registered Nurse

c. "Activities Therapy will educate patient with coping skills to ensure functioning in the community post discharge."
Discipline: Activity Therapist

VIII. Patient A8 (admitted 11/30/19; MTP 12/3/19)

a. "RN will administer patient medication and encourage to participate in the milieu on the unit as to stabilize mood and to promote overall behavioral stability."
Discipline: Team RN

B. Staff Interviews

I. On 12/10/19, at 3:30 p.m. when the surveyor reviewed the treatment plan for Patient A7 with the Director of Social Work, she stated, "There is no responsible social worker identified on the form."

II. The Surveyor, reviewed the treatment plans for patients A6 and A7 with the Director of Nursing. During this review, on 12/10/19 at 2:15 p.m., the Director of Nursing stated, "There is no nurse identified, it is written as Team RN."

C. Policy Review

I. Facility Policy, titled "Treatment Plan," last revised 03/17, section G, states: "The treatment plan specifies the type, amount, frequency, duration, purpose and person (s) responsible for implementing the treatment interventions."

II. Facility Form, titled "Multidisciplinary Master Treatment Plan," updated 2/27/18 has a column that requires the person(s) responsible to have the name and discipline recorded with each multidisciplinary intervention.

Based on record review and interview the facility failed to ensure that social work staff regularly document the treatments provided to the patients including a patient's response to the treatments provided and progress or lack of progress of patients in achieving their treatment goals in the progress notes of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Unit program schedule indicated daily Social Work Process groups scheduled (two (2) per day Monday to Friday and one (1) group on Saturday and Sunday) daily, and yet, there was no treatment and/or progress notes documented by the social work staff. This failure resulted in lack of evidence that social workers were actively involved in the care of the patients.

Findings include

A. Record review

Staff was asked to provide a copy of all groups and progress notes for one (1) week (12/1/19 to 12/7/19) for all eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) for social work staff. There were no treatment notes related to the groups provided or progress notes for social work staff about a patients' progress or lack of progress related to treatment goals identified on the MTP for the eight (8) sample patients.

B. Interview

In a meeting on 12/10/19 at 3:00 p.m. with the Director of Social Services, the absence of social work staffs' treatment and/or progress notes in the records for the sample patients was discussed. The Director agreed with the findings, as well as acknowledged that there was no facility policy regarding documentation requirements.

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

I. The Psychiatric Assessments included an assessment and documentation of a patient's assets/personal attributes in a descriptive manner. (Refer to B117)

II. The interdisciplinary MTPs, developed are:

a. Individualized and comprehensive (Refer to B118);

b. Included problem statements written in behavioral terms (Refer to B119);

c. Goals and Treatment interventions were individualized to patient's presenting problems (Refer to B121 and B122).

These deficiencies result in a failure to guide treatment team members in providing patient focused individualized treatments and potentially, negatively affecting patients' treatment and discharge.

Based on medical record review and staff interview, the Director of Nursing failed to ensure that master treatment plans included specific individualized nursing interventions for eight (8) of eight (8) sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). This failure results in the lack of nursing staff direction in care for these patients in the clinical area.

Findings include:

A. Medical Record Review

I. Patient A1 (admitted 09/29/19; MTP 10/01/19)

a. "RN will administer patient's medications and encourage patient to participate in the milieu on the unit as to promote behavioral stability."

II. Patient A5 (admitted 09/29/19; MTP 10/02/19)

a. "RN will administer patient's medications and encourage to participate in the milieu on the unit as to promote behavioral stability."

b. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."

III. Patient A2 (admitted 10/22/19; MTP 10/25/19)

a. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to promote behavioral stability."

IV. Patient A6 (admitted 11/11/19; MTP 11/14/19)

a. "RN will administer patient's medication and encourage patient to participate in the milieu on the unit as to diminish depressive symptoms and to promote behavioral stability."

b. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."

V. Patient A3 (admitted 11/27/19; MTP 11/28/19)

a. "Nursing will give patient prescribed meds daily; will educate patient weekly on meds effects and importance of taking meds as it relates to paranoid delusions; and will assess patient daily regarding problems."

VI. Patient A7 (admitted 11/28/19; MTP 11/29/19)

a. "Nursing will give patient prescribed meds daily; will educate patient weekly on meds effects and importance of taking meds as it relates to paranoid delusions; and will assess patient daily regarding problems."

b. "Nursing will provide disease management education in order to increase the patient's awareness of; nursing will provide medication education related to; and practitioner will meet with the as needed to provide disease management education and medication education in order to manage active medical problem."

VII. Patient A4 (admitted 11/28/19; MTP 11/30/19)

a. "RN will administer, assess and evaluate the patient for medication efficacy and any adverse symptoms as required."

VIII. Patient A8 (admitted 11/30/19; MTP 12/3/19)

a. "RN will administer patient medication and encourage to participate in the milieu on the unit as to stabilize mood and to promote overall behavioral stability."

B. Staff Interview

The Director of Nursing, on 12/10/19 at 2:15 PM, reviewed the treatment plans for patients A4, A6 and A7 and stated, "You are correct the treatment interventions are generic, role responsibilities related to giving medications as ordered by the physician. They do not specifically identify what the nurse will do in providing individual care to these patients."

In addition, in reviewing the MTP's addressing active medical problems for Patients A5, A6 and A7 he agreed, that the interventions "Are not individualized to any particular disease process or patient medical need.

Based on record review and staff interview, the Director of Social Services failed to adequately supervise and ensure that the social work staff documented:

a. Psychosocial Assessments included clearly identified role in patients' treatment (Refer to B108);

b. Treatment/progress notes for eight (8) of eight (8) sample patients (Refer to B124).