HospitalInspections.org

Based on policy review, and staff and physician interview, the facility failed to: administer a medication as ordered in 1 of 1 sampled patients (Patient #2) receiving a medication; notify a guardian of a change in a patient's condition in 1 of 1 sampled patients (Patient #1); and perform a urine drug screen as ordered in 1 of 1 sampled patients (Patient #8).

Findings included:

1) Review of facility policy titled "MEDICATION ADMINISTRATION" reviewed 9/19/2019 revealed,"...Medications are not given without a physician's order..."

Closed medical review conducted on 11/05/2019 revealed Patient #2 was a 76-year-old female admitted to the facility on 09/26/2019, with a diagnosis of acute psychosis. Review revealed the patient had a medical history of hypothyroidism (a condition in which a gland does not function as well as it should). Review of Medication Orders written by Medical Doctor (MD) #1 revealed, " ... MEDICATION thyroid desiccated DOSE 30 mg (milligrams) ROUTE PO (by mouth) FREQUENCY DAILY Indication: hypothyroid Notes: MUO (May Use Own) ..." Review of the medication administration record revealed the patient never received the medication during her admission to the facility.

Physician interview was conducted with MD #1 on 11/06/2019 at 1030, who did not recall Patient #2. Interview revealed the order was intended for the patient to continue the medication as prescribed utilizing her own supply of the medication. Interview revealed MD #1 was not informed the patient did not receive the medication, and if his order was not being followed, he should have been informed.

Interview was conducted with the Director of Performance Improvement (DPI) on 11/06/2019 at 1055. Interview revealed the Information Technology department for the facility advised that facility admission staff entered MD #1's order for the thyroid desiccated medication, however the system did not relay the order to the facility's pharmacy. Interview revealed no explanation could be given for the "computer glitch."



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2. Review of the Policy and Procedure "Change in Physical Status" last reviewed 01/19 revealed "D. The RN (registered nurse) Change in Physical Status Note shall be used by RNs to document acute changes in an individual's physical condition ...The RN shall: c. Conduct a nursing assessment ...i. In all situations, the RN shall: Document health information, assessment findings, notifications, communication with Physician ...Contact guardian or next of kin in a timely fashion. Document an initial nursing progress note briefly describing the individual's change in physical status ..."

Review on 11/05/2019 of the closed medical record for Patient #1 revealed a 13-year-old female admitted on 08/08/2019 voluntarily with a diagnosis of major depressive disorder and self-injurious behaviors. Review of the orders dated 08/12/2019 at 1526 revealed "Level of Observation: Common Area Observation (CAR). Notes: Pt (patient) broke glasses and used them to harm herself. Start Time: 08/12/2019 at 16:00 Stop Time: 08/14/2019 at 10:15." Review of the Nursing (RN #9) progress note dated 08/13/2019 at 0006 revealed "The pt was in CAR precautions after she tried to cut self using her eye glasses glass as a weapon." Review of the record failed to reveal family notification or RN documentation/assessment of Patient #1 following the incident.

Interview on 11/06/2019 at 1127 with MD #3 revealed she cared for Patient #1 during her hospital admission. Interview revealed MD #3 vaguely recalled Patient #1 used her eye glasses to harm herself but did not recall the specifics. Interview revealed MD #3 didn't recall notifying the family of the incident. Interview revealed the nurses normally notified the family if a patient attempted self-harm.

Interview on 11/07/2019 at 1115 with MHT #3 revealed he vaguely recalled the incident. Interview revealed MHT #3 recalled receiving report on the day of the incident that Patient #1 attempted to harm herself with her glasses, no further details were provided. Interview revealed he was unaware if anyone notified the family.

Interview on 11/07/2019 at 1507 with RN #8 revealed she was the nurse who cared for Patient #1 when she harmed herself with her eye glasses. Interview revealed RN #8 was unable to recall any specifics pertaining to the incident or if she notified Patient #1's family following the incident. Interview revealed it was standard process to notify family, the physician, supervisor, document the incident in the chart and complete an incident report following an incident of patient self-harm.

Interview on 11/08/2019 with the Director of Performance Improvement revealed he reviewed Patient #1's chart and confirmed the record failed to reveal family notification or RN documentation/assessment of Patient #1 following the incident.



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3. Review of the hospital policy titled "LABORATORY SERVICES" last reviewed 01/2019 revealed "...POLICY It is the policy of (hospital) to provide laboratory services through contractual agreements. Specimens will be collected by...authorized (hospital) staff...PROCEDURE...Routine Specimens 1. Routine specimens are to be collected as soon as possible but no later than 24 hours from the time of the order..."

Medical record review revealed Patient (Pt) # 8 was a 16-year-old female that was admitted to the hospital on 10/11/2019 for suicide ideations (thoughts of killing self) and aggressive behaviors. Record review revealed Pt #8 had a history of marijuana, oxycodone and cocaine use. Medical record review revealed that on 10/11/2019 at 1205, Medical Doctor (MD) #3 ordered an "8+ Oxycodone screen" urine drug test. Medical record review revealed that on 10/15/2019 at 1253, MD #3 ordered a "7 Drug-screen" urine drug test. Medical record review failed to provide evidence that a urine drug screen was performed for Pt #8 as ordered on 10/11/2019 and 10/15/2019.

Interview with Registered Nurse (RN) #3 on 11/05/2019 at 1530 revealed that she was aware MD #3 ordered a urine drug screen for Pt #8. Interview revealed the urine drug screen was not completed because there were no urine specimen cups available in the hospital. Interview revealed RN #3 notified the Nursing Supervisor and MD #3 that the urine drug test was not performed because there were no urine specimen cups available in the hospital.

Interview with RN #4 on 11/06/2019 at 1030 revealed that Pt #8's urine drug test was not performed because there were no urine specimen cups available for "multiple days." Interview revealed RN #4 called the other units on the hospital's campus to request urine specimen cups. Interview revealed that by the time the urine specimen cups were available on the unit, Pt #8 had been discharged from the hospital.

Interview with ADON (Assistant Director of Nursing) #1 on 11/06/2019 at 1210 revealed that she was aware that the urine drug screen was not performed for Pt #8 prior to Pt #8's discharge from the hospital.

Interview with the Psychiatrist (MD #3) on 11/06/2019 at 1110 revealed that he ordered a urine drug screen for Pt #8 on 10/11/2019. Interview revealed MD #3 was informed by the nursing staff that the staff was unable to collect a urine specimen. Interview revealed that on 10/15/2019, MD #3 ordered another urine drug screen. Interview revealed he was informed the hospital did not have the supplies needed to collect the urine specimen.

Interview with the Director of Nursing (DON) on 11/06/2019 at 1620 revealed that at no time was the hospital out of urine specimen cups. Interview revealed that the hospital had an "abundant supply" of specimen cups. Interview revealed that the DON was not aware that Pt #8 did not receive a urine drug screen as ordered.

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Based on review of the facility policy, medical record review and staff interview, facility staff failed to ensure an individualized comprehensive treatment plan that included behavioral health and medical needs, and was reviewed with the patient or legal guardian for 6 of 26 sampled patients. (#21, #2, #4, #15, #6, #9 )

The findings included:

Review of the facility's "Interdisciplinary Treatment Plan" policy reviewed January 2019 revealed, "PURPOSE 1. To provide a complete, individualized plan of care based on an assessment of the patient's specific needs and problems. 2. To provide appropriate communication between team members that fosters consistency and continuity in the care of the patient. 3. To formulate a plan of care that meets the patient's objectives and needs. ... POLICY Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision of aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. The team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. ... PROCEDURE 1. Within 16 hours of admission, the RN (registered nurse) will initiated the treatment plan. This initial plan shall include high risk and critical medical problems ... 2. Within 72 hours of admission, members of the treatment team shall further develop the Interdisciplinary Master Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, and emotional and behavioral status. ... 6. The treatment team shall establish a plan for involvement of the family and/or significant others when appropriate. ... 9. The patient signs the treatment plan after review with a member of the treatment team. For children/adolescents, write the treatment plan in age-appropriate language for better understanding. The plan should be reviewed via phone for guardians. ..."

1. Open medical record for Patient #21 revealed a 31 year-old female admitted under petition for involuntary commitment on 10/23/2019 with major depressive disorder, gender dysphoria and anorexia nervosa (eating disorder). Review of the patient's admission "History and Physical" dated 10/23/2019 recorded the patient was admitted with a suicide plan. Review revealed the patient had an active eating disorder. Review of the patient's "Psychosocial Assessment" documented by the therapist on 10/24/2019 at 1401 revealed the patient had an eating disorder and a long history of personality disorders. Review of a "Symptom Checklist" completed by the patient (not dated) revealed the patient was " using alcohol to eat due to eating disorder symptoms." Review revealed the patient identified "food" as a trigger and stressor and listed "not eating" as a "warning sign" that she was nearing a crisis. Review of a "Comprehensive Assessment Tool - Adult Intake" signed on 10/23/2019 at 1630 revealed the patient had a history of anorexia. Review of the presenting problem revealed the patient reported she had bipolar disorder and an eating disorder and was having difficulty finding placement. Review revealed the patient had been to eight eating disorder programs in the past two years. Review revealed the patient had not been taking her medications and had stopped eating. Review of a "Comprehensive Nursing Assessment" signed by an registered nurse on 10/23/2019 at 2300 revealed the patient had an eating disorder that caused "spontaneous regurgitation." Review of a nursing note dated 10/23/2019 at 2300 recorded "IVC (involuntary commitment) admitted to unit ...Pt (patient) also has atypical anorexia r/t (related to) past trauma. ..." Review of a "Nursing Flow Sheet/Progress Record" dated 10/24/2019 Nights recorded the patient reported she had an eating disorder and was not going to breakfast. Review of the evening note revealed the patient was not eating and taking in very little fluid. Review of a nursing note dated 10/24/2019 at 1400 recorded the patient was refusing to eat and drink and the psychiatrist was notified. Review of a nursing note at 2230 recorded the patient complained of an irregular heartbeat (with a history of left ventricular hypertrophy - enlarged heart). Review revealed a Medical Consult was conducted on 10/24/2019 (not timed) that recorded a diagnosis of "anorexia" and a plan to transfer the patient to an acute hospital if the patient became unstable. Review of nursing notes at 2330 recorded the patient complained of stabbing in the left chest area. Review revealed the physician was notified and the patient was sent via ambulance to an acute hospital for evaluation. Review of a nursing note dated 10/25/19 at 0315 revealed the patient returned from the acute hospital. Review revealed the patient had a "Dietary Consult" on 10/25/2019 at 1215. Review of the Registered Dietician's note recorded the patient had a history of eating disorder since age 4. Review revealed the patient would be amenable to long term tube feedings for nutrition. Review revealed a recommendation from the registered dietician for inpatient facility treatment for the patient's eating disorder. Review of a nursing note dated 10/25/2019 at 0900 recorded the patient was refusing to eat or drink. Review of a psychiatrist note dated 10/25/2019 recorded the patient reported poor appetite. Review of the patient's "Daily Patient Inventory: Morning" documented by the patient on 10/25/2019 at 1000 recorded the patient had no appetite, was purging and described food as causing a panic attack. Review of the patient's "Daily Patient Inventory: Morning" documented by the patient on 10/26/2019 at 1200 recorded the patient had no appetite, was purging after one bite and described lunch as causing an anxiety attack. Review of the patient's "Daily Patient Inventory: Evening" documented by the patient on 10/26/2019 at 2114 recorded the patient had no appetite or thirst and was purging. Review of a Registered Dietician note dated 10/28/2019 at 1115 recorded the patient had a 5 pound weight loss since admission. The note recorded the patient was eating small amounts and continued to purge her food. The note recorded that the patient purged five times over the weekend and was not keeping fluids down. Review of the note revealed the patient reported some blood in her emesis and the patient was concerned about refeeding syndrome. Review of the notes recorded "will continue to monitor." Review of a psychiatry note dated 10/28/2019 at 1100 recorded the patient had a change in appetite. Review of the patient's "Daily Patient Inventory: Evening" documented by the patient on 10/28/2019 at 2240 recorded the patient was purging. Review of a Registered Dietician note recorded on 10/31/2019 at 1204 revealed lab results were evaluated and the dietician met with the patient. Review of the notes recorded that the patient continued to purge and regurgitate all foods she eats. The notes stated the writer observed this behavior on the day of the recorded note. Review of the patient's "Daily Patient Inventory: Evening" documented by the patient on 10/29/2019 (not timed) recorded the patient was purging everything she ate and that food was causing panic attacks. Review of nursing notes, psychiatric notes and patient self-inventory notes on 10/29/201; 10/30/2019; 10/31/2019; 11/01/2019; 11/02/2019; 11/03/2019; 11/04/2019; 11/05/2019; and 11/06/2019 recorded documentation of the patient continuing to purge her food. Review of a nursing note dated 11/06/2019 at 1015 recorded the patient reported suicide ideations with a plan to "purge until my body gives out." Review revealed the psychiatrist and the patient's therapist were made aware of the patient's plan with no new orders received.

Review of the MTP for Patient #21 dated 10/24/2019 revealed two problem areas identified. The first problem was listed as "suicide ideations" and another problem listed as "left ventricular heart valve disorder." Review of the MTP failed to reveal a problem identified for eating disorder. Review of the MTP dated 10/24/2019 revealed a section for the patient to sign and date with a pre-printed stated that stated, "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." Review revealed the patient signature was blank. Review revealed an updated treatment plan review dated 10/30/2019 at 1140 that recorded the patient denied suicide ideations and was engaging in group. Review failed to reveal any documentation of a problem or interventions to address the patient's eating disorder. Review of the MTP update toward goals dated 10/30/2019 revealed the section for the patient's signature and date indicating the treatment plan was reviewed with the patient was blank.

Interview on 11/07/2019 at 1105 with Patient #21 revealed the patient was transferred to the current hospital from another acute hospital because she was not taking her medications and was suicidal. Interview revealed the patient had an eating disorder and she was actively trying to find an eating disorder program that would admit her for treatment. The patient stated "They are not able to help me here with my eating disorder." Interview revealed the patient was purging food daily and it had gotten worse over the past two days. The patient reported she had not had any one to one therapy sessions since she was admitted. The patient stated her treatment plan was "vague" and her treatment goal was to go to an eating disorder treatment center. The patient stated that had been her goal since she was admitted. Interview revealed the patient was suicidal on admission, but described her eating disorder as her biggest problem now. Patient #21 reported that no one had talked with her about her treatment plan or goals since admission.

Interview on 11/07/2019 at 1305 with RN #13 revealed she was the patient's primary nurse. Interview with the nurse revealed the patient has had an eating disorder since admission and that she purges at least one time a day while the day shift nurse was on duty. Interview with the nurse revealed the patient had a "lot of triggers related to food." The nurse reported that the patient had no problem area or interventions identified on her MTP related to an eating disorder. RN #13 was unable to explain why there was no identified problem or interventions related to the patient eating disorder on the MTP.

Interview on 11/07/2019 at 1310 with Therapist #3 revealed she was a prn (as needed coverage) therapist that was covering for the regular therapist that normally worked with Patient #21. Interview revealed the patient had reported in group that she had been binging and purging and that she wanted to eat. Therapist #3 reviewed the patient MTP and stated "I don't see food disorder listed as a problem and it should be. The patient stated her goal was to keep food down and not throw it back up." The therapist reported her interactions with Patient #21 revealed her primary issue was her eating disorder. Interview revealed there was no patient signature on the MTP indicating that the treatment plan had been reviewed with Patient #21.

Interview on 11/07/2019 at 1515 with MD #4 revealed Patient #21 had a history of an eating disorder since childhood and was having difficulty finding placement in an eating disorder program due to insurance and her dual diagnosis. The psychiatrist reported the patient's purging had become worse recently and he was monitoring her labs. When asked about her MTP problems list, the psychiatrist stated her eating disorder and borderline personality disorder were her primary problems. The psychiatrist was unable to explain why these two problem areas were not on the patient's MTP problem list.



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2. Closed medical record review for Patient #2 revealed a 76-year-old female admitted under petition for involuntary commitment on 09/26/2019 with acute psychosis. Review revealed Patient #2 had a past medical history including Hypothyroidism. Review of an Individualized Treatment Plan written on 09/27/2019 revealed, "take meds as prescribed." Review of Medication Orders written by Medical Doctor (MD) #1 revealed, "... MEDICATION thyroid desiccated DOSE 30 mg (milligrams) ROUTE PO (by mouth) FREQUENCY DAILY Indication: hypothyroid Notes: MUO (May Use Own) ..." Review of the medication administration record revealed the patient never received the medication during her admission to the facility, which ended on 10/07/2019.

Physician interview was conducted with MD #1 on 11/06/2019 at 1030, who did not recall Patient #2. Interview revealed the order was intended for the patient to continue the medication as prescribed utilizing her own supply of the medication. Interview revealed MD #1 was not informed the patient did not receive the medication, and if his order was not being followed, he should have been informed. Interview revealed the Individualized Treatment Plan intervention to "take meds as prescribed" was not implemented

3. Closed medical record review for Patient #4 revealed a 25-year-old female admitted under petition for involuntary commitment on 09/16/2019 with psychosis. Review revealed Patient #4 had a past medical history including seizures. Review of an Interdisciplinary Master Treatment Plan revealed seizures listed as an active medical diagnosis. Review revealed no evidence of a treatment plan regarding seizures.

Interview was conducted with the Director of Performance Improvement (DPI) on 11/06/2019 at 1055. Interview revealed the past medical history of seizures should have been identified on the patient's Interdisciplinary Master Treatment Plan and it was not there.



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4. Open medical record review on 11/05/2019 revealed on 10/30/2019, Patient #15, a 54 year-old was involuntarily admitted to the facility for schizophrenia. Review of Patient #15's MTP revealed it was completed on 11/01/2019. Review revealed "Patient Participation: Contributed to goal/plan (left blank) Aware of plan content (left blank)" and a place for a patient signature to acknowledge "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." Review revealed the patient signature space is blank. Review of the record revealed patient signature had not been obtained as of survey exit on 11/08/2019. (7 days after admission)

Interview on 11/05/2019 at 1145 with Patient #15 revealed he was aware of the reason for his admission and he realized he needed help. Intervew revealed he is aware of his delusions and they feel real to him. Interview revealed he has not spoken to anyone about his treatment plan, but he has participated in groups. Interview revealed he has not signed any paperwork reviewing a treatment plan nor has anyone spoken to him about his discharge plans or any outpatient treatment options.

Interview on 11/05/2019 at 1205 with Therapist #2 revealed Patient #15 is aware of his treatment because he is in group. Interview revealed "he's delusional". Interview revealed she typically meets with the patient the day the treatment plan is created or within 24 hours to explain the treatment plan. Interview confirmed she has not met with Patient #15. Interview revealed patients do not participate in treatment team.

5. Closed medical record review on 11/05/2019 revealed on 10/08/2019, Patient #6, a 16 year-old was involuntarily admitted to the facility for substance abuse and depression. Review of Patient #15's MTP revealed it was completed on 10/10/2019. Review revealed "Patient Participation: Patient has legal guardian (left blank) Contributed to goal/plan (left blank) Aware of plan content (left blank)" and a place for a patient signature to acknowledge "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." Review revealed the patient signature space is blank. Review revealed space for documentation to review with legal guardian is blank. Review of record revealed no documentation of treatment plan discussion with the patient or guardian.

Interview on 11/06/2019 at 1045 with Therapist #4 revealed she was in orientation during Patient #6 admission. Interview revealed MTP are discussed with the Pateint and Guardian and should be documented in the medical record. Interview confirmed no documentation of discussion of treatment plan discussion with the patient or guardian in the medical record.



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6. Closed medical record review on 11/05/2019 revealed, Patient #9, a 58 year-old female was involuntarily admitted to the facility for suicidal ideation and aggression toward a non-relative household member with whom she lived. Review revealed a DSS guardian had intervened in the aggression and petitioned for involuntary admission to the facility. Review of the MTP for Patient #9 dated 10/25/2019 revealed four active medical problem areas identified. The first problem was listed as "DM Type II, low potassium, COPD," and "hypertension." Review of the MTP dated 10/25/2019 revealed a section for the patient to sign and date with a pre-printed statement indicating, "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." Review revealed the patient signature area was blank, telephone review with the guardian was not indicated as completed, and there was no staff signature or indication review was attempted with the patient or guardian.

Interview with a case manager, Therapist #3, on 11/06/2019 at 1155 revealed she had worked with and recalled Patient #9 and had been her primary case therapist. Therapist #3 recalled when Patient #9 "first came in she did not want me to talk with" her outpatient case worker and had been "very upset and was refusing to do things." Therapist #3 stated "I think I forgot to document her response to the (master) treatment plan."

Based on policy review, medical record review and staff interview, the treatment team failed to delineate specific measurable short-term and long-term patient centered goals based on individual patient problems and failed to ensure short and long term goals had expected completion dates for 6 of 26 patients reviewed (#21, #26, #17, #20, #13, #9). This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions.

The findings included:

Review of the facility's "Interdisciplinary Treatment Plan" policy reviewed January 2019 revealed, "... POLICY Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision of aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. The team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. ... PROCEDURE ... 3. The treatment plan shall contain certain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as the person responsible for implementation. ... 7. The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record. ... Treatment Team Components ... Long-term Goal: The long-term goal(s) for the problem is the specific behaviors that will hope to be seen at the time of discharge from this episode of treatment (and level of care). Short-term Goal: Short-term goals are stated as "stepping stones" to the long-term goals and are stated in specific behavioral, observable terms. A target date will be established for each short-term goal. ..."

1. Open medical record for Patient #21 revealed a 31 year-old female admitted under petition for involuntary commitment on 10/23/2019 with major depressive disorder, gender dysphoria and anorexia nervosa (eating disorder). Review of the MTP dated 10/24/2019 listed a medical problem as "Left ventricular heart valve disorder." Review of the "Long Term Goal" revealed the area was blank with no long term goal identified.

Interview on 11/07/2019 at 1305 with RN #13 revealed long-term and short-term goals are established in treatment team for each problem identified. Interview revealed the goals are individualized and measurable for each problem and are reevaluated to determine progress weekly. Review of Patient #21's goals revealed the long term goal was left blank and not defined according to policy. Interview revealed RN #13 was unable to provide a rationale as to why the long term goal was left blank.

2. Open medical record review of Patient #26 revealed a 60 year-old male admitted on 11/04/2019 with bipolar disorder and substance abuse. Review of the record revealed the patient had a recent fracture to his left foot. Review of the MTP dated 11/07/2019 listed Problem #1 as "Suicide Gestures." Review of the "Patient Long Term Goals" and "Short Term Goals" revealed the target dates for completion were blank with no target dates identified. Review of the MTP dated 11/07/2019 listed Problem #2 as "Use of Alcohol in combination of other substnance." Review of the "Patient Long Term Goals" and "Short Term Goals" revealed the target dates for completion were blank with no target dates identified.

Interview on 11/08/2019 at 0950 with RN #12 revealed long-term and short-term goals are established in treatment team for each problem identified, along with target dates for completion. Interview revealed the goals are individualized and measurable for each problem and are reevaluated to determine progress weekly. Review of Patient #26's goals revealed the long term and short term target dates for completion of goals were left blank and not defined according to policy. Interview revealed RN #12 was unable to provide a rationale as to why the short and long term target dates for completion of goals were left blank.



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3. Open medical record review on 11/06/2019 revealed on 10/29/2019, Patient #17, a 14 year-old was involuntarily admitted to the facility for anxiety and major depressive disorder. Review of the MTP dated 10/29/2019 revealed "Long Term Goal As Expressed by Patient: 1) Pt will report no suicideal ideations for 3 days prior to...." Review revealed long term goal is incomplete. Further review of record revealed a MTP update was completed on 11/05/2019 for identifed problem #1of "SI" (Suicidal Ideation). Review revealed "Updated Target Date" is blank.

Interview on 11/06/2019 at 1045 with Therapist #4 revealed Target dates should be the date of the next update. Interview revealed the target date should have been documented. Interview confirmed the date was blank.

4. Open medical record review on 11/06/2019 revealed on 10/28/2019, Patient #20, a 20 year-old was voluntarily admitted to the facility for schizoaffective disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 10/29/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Further review of record revealed a MTP update was completed on 11/04/2019 for identifed problem #1of Schizoaffective Disorder. Review revealed "Updated Target Date" is blank.

Interview on 11/06/2019 at 1045 with Therapist #4 revealed Target dates should be the date of the next update. Interview revealed the target date should have been documented. Interview confirmed the date was blank.


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5. Closed medical record review for Patient #13 revealed a 27-year-old male admitted under petition for involuntary commitment on 09/27/2019 with psychotic behavior. Review of an Interdisciplinary Master Treatment Plan written on 10/04/2019 revealed " ...Problem 1: Psychosis Updated Target Date: TBD (to be determined) Progress toward goals: Pt. is med compliant and refuses to attend treatment groups. Problem 2: Substance Abuse Updated Target Date: TBD Progress toward goals: Pt. is completing the detoxification process ..." Review revealed no evidence of a specific target date for Patient #13's goals.

Interview on 11/06/2019 at 1045 with Therapist #4 revealed Target dates should be the date of the next update. Interview revealed the target date should have been documented. Interview confirmed the date was blank.


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6. Closed medical record review on 11/05/2019 revealed, Patient #9, a 58 year-old female was involuntarily admitted to the facility for suicidal ideation and aggression toward a non-relative household member with whom she lived. Review of the "Patient Long Term Goals" and "Short Term Goals" revealed the target dates for review and update were 10/31/2019 and 11/01/2019. Review revealed no indication the goals had been achieved or updated on 10/31/2019 or 11/01/2019 and no indication the goals had been achieved by discharge on 11/04/2019.

Interview with a case manager, Therapist #3 , on 11/06/2019 at 1155 revealed she had worked with and recalled Patient #9 and had been her primary case therapist. Therapist #3 recalled she had met with Patient #9 and the guardian on 11/04/2019, the day of discharge. Therapist #3 stated Patient #9 had signed the "Aftercare Instructions" but Therapist #3 had not documented the interaction and "I should have documented it."

Based on facility policy review, medical record review and staff interview, the facility failed to provide Master Treatment Plans (MTPs) for 26 of 26 sampled patients (#6, #15, #16, #17, #19, #20, #5, #25, #26, #12, #14,
#21, #2, #4, #13, #22, #18, #9, #1, #3, #7, #10, #11, #8, #23, #24) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. Specifically, MTPs failed to include a focus of treatment based on each patient's unique presenting symptoms.

The findings included:

Review of the facility's "Interdisciplinary Treatment Plan" policy reviewed January 2019 revealed, "... POLICY Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision of aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. The team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. ... PROCEDURE ... 3. The treatment plan shall contain certain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as the person responsible for implementation. ... 7. The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record. ... Treatment Team Components ... Interventions: Interventions for each appropriate discipline will be included for each problem. The intervention includes the following components: Intervention Strategies and Modality: Specific intervention(group therapy, administration of antidepressant, activities therapy, psych testing, 1:1, suicide precautions, etc.). Frequency: How often the intervention will be done (daily, 5 times per week, each shift, every 15 minutes, as needed). Responsible Staff: The names and credentials/discipline of the specific staff members responsible for the provision of the intervention. ..."

1. Closed medical record review on 11/05/2019 revealed on 10/08/2019, Patient #6, a 16-year-old was involuntarily admitted to the facility for substance abuse and depression. Review of the Therapist intervention strategies of the MTP dated 10/10/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

2. Open medical record review on 11/05/2019 revealed on 10/30/2019, Patient #15, a 54-year-old was involuntarily admitted to the facility for schizophrenia. Review of the Therapist intervention strategies of the MTP dated 11/01/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable

3.Open medical record review on 11/05/2019 revealed on 10/16/2019, Patient #16, a 59-year-old was involuntarily admitted to the facility for schizophrenia. Review of the Therapist intervention strategies of the MTP dated 10/18/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

4. Open medical record review on 11/06/2019 revealed on 10/29/2019, Patient #17, a 14-year-old was involuntarily admitted to the facility for anxiety and major depressive disorder. Review of the Therapist intervention strategies of the MTP dated 10/30/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable

5. Closed medical record review on 11/06/2019 revealed on 09/18/2019, Patient #19, a 44 year-old was involuntarily admitted to the facility for schizoaffective disorder. Review of the Therapist intervention strategies of the MTP dated 09/18/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable

6. Open medical record review on 11/06/2019 revealed on 10/28/2019, Patient #20, a 20 year-old was voluntarily admitted to the facility for schizoaffective disorder. Review of the Therapist intervention strategies of the MTP dated 10/29/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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7. Closed medical record for Patient #5 revealed a 14-year-old male admitted on 09/10/2019 under petition for involuntary commitment with suicide ideations, anxiety disorder, autistic and Asperger's syndrome. Review of the Therapist intervention strategies of the MTP dated 09/12/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

8. Open medical record for Patient #25 revealed a 57-year-old male admitted on 10/28/2019 with schizophrenia disorder, bipolar type and substance abuse. Review of the Therapist intervention strategies of the MTP dated 10/30/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

9. Open medical record for Patient #26 revealed a 60-year-old male admitted on 11/04/2019 with bipolar type and substance abuse. Review of the Therapist intervention strategies of the MTP dated 11/07/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

10. Open medical record for Patient #12 revealed a 10-year-old female admitted under petition for involuntary commitment on 10/30/2019 with post traumatic stress disorder. Review of the Therapist intervention strategies of the MTP dated 11/02/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

11. Open medical record for Patient #14 revealed a 28-year-old female admitted under petition for involuntary commitment on 11/04/2019 with schitzophrenia, chronic paranoid, severe. Review of the Therapist intervention strategies of the MTP dated 11/06/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

12. Open medical record for Patient #21 revealed a 31-year-old female admitted under petition for involuntary commitment on 10/23/2019 with major depressive disorder, gender dysphoria and anorexia nervosa (eating disorder). Review of the Therapist intervention strategies of the MTP dated 10/24/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount ; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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13. Closed medical record review on 11/05/2019 revealed on 09/12/2019, Patient #2, a 76-year-old female was involuntarily admitted to the facility for acute psychosis. Review of the Therapist intervention strategies of the MTP dated 09/26/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

14. Closed medical record review on 11/05/2019 revealed on 09/12/2019, Patient #4, a 25-year-old female was involuntarily admitted to the facility for psychosis. Review of the Therapist intervention strategies of the MTP dated 09/16/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

15. Closed medical record review on 11/05/2019 revealed on 09/27/2019, Patient #13, a 27-year-old male was involuntarily admitted to the facility for psychotic behavior. Review of the Therapist intervention strategies of the MTP dated 09/30/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

16. Closed medical record review on 11/05/2019 revealed on 10/24/2019, Patient #22, a 38-year-old female was involuntarily admitted to the facility after an overdose attempt. Review of the Therapist intervention strategies of the MTP dated 10/25/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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17. Open medical record review on 11/07/2019 revealed, Patient #18, a 19-year-old female was voluntarily admitted to the facility for depression and suicidal ideation with a plan. Review of the Therapist intervention strategies on the MTP dated 10/31/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

18. Closed medical record review on 11/05/2019 revealed, Patient #9, a 58-year-old female was involuntarily admitted to the facility on 10/24/2019 for suicidal ideation and aggression toward a non-relative household member with whom she lived. Review of the Therapist intervention strategies of the MTP dated 10/24/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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19. Closed medical record for Patient #1 revealed a 60-year-old female admitted on 07/29/2019 under petition for involuntary commitment following an intentional overdose. Review of the Therapist intervention strategies of the MTP dated 08/01/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

20. Closed medical record for Patient #3 revealed a 13-year-old female admitted on 08/08/2019 voluntarily with a diagnosis of major depressive disorder and self-injurious behaviors. Review of the Therapist intervention strategies of the MTP dated 08/08/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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21. Closed medical record review on 11/05/2019 revealed on 09/21/2019, Patient #7, a 12-year-old was voluntarily admitted to the facility for suicidal ideation and homicidal ideation . Review of the Therapist intervention strategies of the MTP dated 09/24/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

22. Closed medical record review on 11/05/2019 revealed on 09/12/2019, Patient #10, an 11-year-old was involuntarily admitted to the facility for aggression and reported auditory hallucination. Review of the Therapist intervention strategies of the MTP dated 09/12/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

23. Closed medical record review on 11/05/2019 revealed on 08/30/2019, Patient #11, an 8-year-old was voluntarily admitted to the facility for SI/SIB, aggression, and sexually inappropriate behavior. Review revealed the Therapist intervention strategies of the MTP dated 09/02/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount; PRN; Frequency; 1 minimum". Review revealed no specific timeframes for time/date and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount time for each session. The staff member reviewed the Therapy section on teh MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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24. Closed medical record review for Patient #8 revealed a 16-year-old female admitted on 10/11/2019 for suicide ideations and aggressive behaviors. Review of the Therapist intervention strategies of the MTP dated 10/11/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount PRN; Frequency 1 minimum." Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

25. Open medical record review for Patient #23 revealed a 16-year-old male admitted on 10/29/2019 with Major depressive disorder and aggression. Review of the Therapist intervention strategies of the MTP dated 10/29/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount PRN; Frequency 1 minimum." Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

26. Open medical record review for Patient #24 revealed a 17-year-old female admitted on 10/14/2019 with Generalized anxiety disorder and Major depressive disorder. Review of the Therapist intervention strategies of the MTP dated 10/14/2019 revealed Discharge Planning, Crisis Safety Planning and Family/Support System Therapy. Review revealed "Modality Indiv/Family; Amount PRN; Frequency 1 minimum." Review revealed no specific timeframes for time/day and times/week. Review revealed PRN does not define a specific amount for time/day for the modality.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by number of days per week and a specific amount of time for each session. The staff member reviewed the Therapy section on the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

Based on policy review, medical record review and staff interview, the facility staff failed to include responsibilities of each member of the treatment team for 2 of 26 sampled patients (#19 and #9).

The findings include:

Review of the facility's "Interdisciplinary Treatment Plan" policy reviewed January 2019 revealed, "... POLICY Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision of aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. The team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. ... PROCEDURE 1. Within 16 hours of admission, the RN (registered nurse) will initiated the treatment plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing interventions as determined by the initial assessments, the Physician's Treatment Plan, and the physician's orders. ... 3. The treatment plan shall contain certain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as the person responsible for implementation. ... Treatment Team Components ... Interventions: Interventions for each appropriate discipline will be included for each problem. The intervention includes the following components: Intervention Strategies and Modality: Specific intervention (group therapy, administration of antidepressant, activities therapy, psych testing, 1:1, suicide precautions, etc.). Frequency: How often the intervention will be done (daily, 5 times per week, each shift, every 15 minutes, as needed). Responsible Staff: The names and credentials/discipline of the specific staff members responsible for the provision of the intervention. ..."

1. Closed medical record review on 11/06/2019 revealed on 09/18/2019, Patient #19, a 44-year-old was involuntarily admitted to the facility for schizoaffective disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 09/18/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed no physician interventions were documented for the idenified problem of "Psychosis". Further review revealed the responsible staff member "Name and Credentials" for "Physician Interventions" were also blank on the MTP.

Interview on 11/05/2019 at 1530 with Therapist #2 revealed the physician is supposed to have is interventions filled in and signed off. I usually make sure the MTPs are complete. Interview confirmed. Interventions and assigned responsibilities are not complete.



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2. Closed medical record review on 11/05/2019 revealed, Patient #9, a 58-year-old female was involuntarily admitted to the facility on 10/24/2019 for suicidal ideation and aggression toward a non-relative household member. Review of the Intervention strategies for the goals on the MTP dated 10/24/2019 and 10/25/2019 revealed no MD staff member signature for patient blood sugar medication management, patient blood pressure medication management, patient respiratory medication management and a registered nurse signature indicating responsibility for managing neuropathic (nerve) pain medication.

Interview on 11/07/2019 at 1250 with the Chief Clinical Officer revealed once long and short term goals are determined and entered on the master treatment plan each member of the treatment team is expected to sign the sheet in the sections relevant to their role on the team.

Based on the facility's policy, medical record review and staff interview, the facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 13 of 26 sampled patients (#5, #25, #2, #13, #6, #16, #19, #20, #9, #18, #3, #23, #24).

The findings include:

Review of the facility's "Interdisciplinary Treatment Plan" policy reviewed January 2019 revealed, "PURPOSE 1. To provide a complete, individualized plan of care based on an assessment of the patient's specific needs and problems. 2. To provide appropriate communication between team members that fosters consistency and continuity in the care of the patient. 3. To formulate a plan of care that meets the patient's objectives and needs. ... POLICY Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision of aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. The team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate. ... PROCEDURE 1. Within 16 hours of admission, the RN (registered nurse) will initiated the treatment plan. This initial plan shall include high risk and critical medical problems ... 2. Within 72 hours of admission, members of the treatment team shall further develop the Interdisciplinary Master Treatment Plan (MTP) that is based on a comprehensive assessment of the patient's presenting problems, physical health, and emotional and behavioral status. 3. The treatment plan shall contain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as the person responsible for implementation. ...7. The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record. ... 10. The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum the treatment plan is to be reviewed weekly. 11. Treatment plan reviews and updates shall include the following steps: a. Review of progress towards goals and effectiveness of interventions for each open problem on the Problem List. b. Modifications or additions made to goals and interventions as appropriate...."

1. Review on 11/06/2019 of a closed medical record for Patient #5 revealed a 14-year-old male admitted on 09/10/2019 with suicide ideations, anxiety disorder, autistic and Asperger's syndrome. Review of the "Interdisciplinary Master Treatment Plan" dated 09/12/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review revealed an additional problem was identified on 09/25/2019 related to restraint use. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals. Review revealed the patient discharged home on 10/07/2019 (27 days after admission).

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. The staff member reviewed Patient #5's medical record and stated the evaluation "was not completed." Interview revealed a treatment plan update and documentation of progress toward was to be evaluated on 09/17/2019; 09/24/2019 and 10/01/2019. Interview revealed the facility policy was not followed.

2. Review on 11/07/2019 of a open medical record for Patient #25 revealed a 57-year-old male admitted on 10/28/2019 with schizophrenia disorder, bipolar type and substance abuse. Review of the MTP dated 10/30/2019 revealed the plan included four identified problems with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for the problem areas that included the type of intervention and responsible individual. Review of the record on 11/08/2019 (11 days after admission) revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals.

Observation on 11/08/2019 at 1010 of a treatment team meeting revealed Patient #25 was discussed by his psychiatrist, therapist and a nurse. Observation revealed discussion included a plan to discharge the patient to a group home on November 12, 2019.

Interview on 11/07/2019 at 1100 with Therapist #3 revealed an evaluation of the treatment plan intervention and progress toward goals should have been completed and documented on 11/04/2019. Interview revealed the review of progress toward goals was not reviewed until 11/08/2019 (11 days after admission). Interview revealed facility staff failed to follow the facility policy.



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3. Review on 11/05/2019 of a closed medical record for Patient #2 revealed a 76-year-old female admitted on 09/12/2019 under involuntary commitment with acute psychosis. Review of the "Interdisciplinary Master Treatment Plan" dated 09/27/2019 revealed the plan included one identified problem with a long-term goal of "normal thyroid level" and a short-term goal of "take meds as prescribed" with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals. Review revealed the patient discharged home on 10/07/2019.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

4. Review on 11/06/2019 of a closed medical record for Patient #13 revealed a 27-year-old male admitted on 09/27/2019 under involuntary commitment with psychotic behavior. Review of Patient #13's Interdisciplinary Master Treatment Plans revealed between 10/10/2019 and 10/24/2019 (14 days) the patient's progress towards the goal of compliance with medication was not updated. Review revealed the patient discharged home on 10/29/2019.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.


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5. Closed medical record review on 11/05/2019 revealed on 10/08/2019, Patient #6, a 16-year-old was involuntarily admitted to the facility for substance abuse and depression. Review of the "Interdisciplinary Master Treatment Plan" dated 10/09/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals. Review revealed the patient discharged home on 10/19/2019 (11 days after admission).

Interview on 11/06/2019 at 1045 with Therapist #4 revealed she was orientation during Patient #6 admission. Interview revealed MTP updates need to be done every 7 days. Interview confirmed Patient #6 did not have an update during his admission.

6. Open medical record review on 11/05/2019 revealed on 10/16/2019, Patient #16, a 59-year-old was involuntarily admitted to the facility for schizophrenia. Review of the "Interdisciplinary Master Treatment Plan" dated 10/18/2019 revealed the plan included two identified problem with long term and short term goals with no target dates for completion recorded for the problem idendified related to hypertension. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review revealed the MTP was updated on 10/30/2019 (11 days after original plan was created). Review revealed the update was not completed within the 7 day timeframe.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

7. Closed medical record review on 11/06/2019 revealed on 09/18/2019, Patient #19, a 44-year-old was involuntarily admitted to the facility for schizoaffective disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 09/18/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed the MTP was updated on 09/05/2019 and 10/12/19 (17 days after the first). Review revealed the update was not completed within the 7 day timeframe.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

8. Open medical record review on 11/06/2019 revealed on 10/28/2019, Patient #20, a 20-year-old was voluntarily admitted to the facility for schizoaffective disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 10/29/2019 revealed the plan included one identified problem with long term and short term goals with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review revealed the MTP was updated on 11/04/2019. Review of the Nursing portion of the MTP revealed it was blank.

Interview on 11/06/2018 at 1440 with RN #13 revealed the nursing update should have been completed when the MTP was updated. Interview confirmed the nursing update was incomplete.



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9. Closed medical record review on 11/05/2019 revealed, Patient #9, a 58-year-old female was involuntarily admitted to the facility on 10/24/2019 for suicidal ideation and aggression toward a non-relative household member with whom she lived. Review of the "Interdisciplinary Master Treatment Plan" dated 10/24/2019 and 10/25/2019 revealed the plan included five identified problems with long term and short-term goals with target dates for completion or update recorded for 10/31/2019 or 11/01/2019. Review revealed interventions were identified for the problem areas that included the type of intervention and responsible individual. Review of the record on 11/05/2019 revealed no documentation of evaluations of the patient's response to the treatment or progress toward treatment goals.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

10. Open medical record review on 11/07/2019 revealed, Patient #18, a 19-year-old female was voluntarily admitted to the facility on 10/31/2019 for depression and suicidal ideation with a plan. Review of the "Interdisciplinary Master Treatment Plan" dated 10/31/2019 revealed the plan included one identified problem with long term and short-term goals with target dates for completion or update recorded for 11/07/2019. Review revealed interventions were identified for the problem areas that included the type of intervention and responsible individual. Review of the record on 11/08/2019 revealed no documentation of evaluations of the patient's response to the treatment or progress toward treatment goals.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.



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11. Closed medical record for Patient #3 revealed a 13-year-old female admitted on 08/08/2019 voluntarily with a diagnosis of major depressive disorder and self-injurious behaviors. Review of the MTP dated 08/08/2019 revealed the plan included two identified problems with long term and short-term goals with target dates for completion recorded. Review revealed interventions were identified for the problem areas that included the type of intervention and responsible individual. Review of the record on 08/15/2019 (7 days after admission) revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.


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12. Review on 11/05/2019 of an open medical record for Patient #23 revealed a 16-year-old male admitted on 10/29/2019 with Major depressive disorder and aggression. Review of the "Interdisciplinary Master Treatment Plan" dated 10/29/2019 revealed the plan included one identified problem with long term and short-term goals with target dates for completion recorded. Review revealed interventions were identified for the problem area that included the type of intervention and responsible individual. Review of the record revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

13. Review on 11/05/2019 of an open medical record for Patient #24 revealed a 17-year-old female admitted on 10/14/2019 with Generalized anxiety disorder and Major depressive disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 10/14/2019 revealed the plan included one identified problem with long term and short-term goals with target dates for completion recorded. Review revealed interventions were identified for the problem areas that included the type of intervention and responsible individual. Review of the record on 11/06/2019 revealed no documentation of an evaluation of the patient's response to the treatment or progress toward treatment goals.

Interview on 11/07/2019 at 1020 with the Chief Clinical Officer revealed an evaluation of the treatment plan intervention and progress toward goals should be completed seven days from admission and every seven days until discharge. Interview revealed the facility policy was not followed.

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