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Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
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A-0701 - Failure to ensure the physical environment of the hospital was developed and maintained to assure the safety and well-being of patients

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation and interview and during the tour of the facility on 4/17/17 between 0900 and 1600 the facility failed to maintain the hospital environment to ensure a safe and sanitary environment resulting in the potential for transmission of infectious agents to all patients served by the facility. Findings include:

1. The typical patient floor water fountain had been removed from each floor leaving behind a huge wall cavity and the metal hanger where the fountain used to be seated on is left exposed. This is a potential for patient harming him/herself.

2. The typical isolation room 127, 227, 327, 427, 527, and 627 are not equipped with the required exhaust system in the patient room. Typical patient isolation room shall be on negative pressure with a minimum of 12 air changes per hour (AC).

3. The typical patient room 228, 328, 428, 528, and 628 have been converted into exam room sometime ago. These rooms do not have the required handwashing sink inside. However, there is a handwashing sink inside the adjacent toilet room by utilizing the access door to and from the bathroom.

4. The drain line for the ice/water machine serving the typical kitchenette of each of the six patient floors was observed below the rim of the receiving drain, without the required air gap of at least 1 inch of unobstructed space.

5. The newly renovated central bathing room and the water closet on each of the patient floors did not have the required grab bars.

6. The typical patient room's as well as the day/dining room's window sill marble sections were noted to be broken and/or loose potentially allowing them to be used to either break the room window or simply harm the next patient and/or staff. This repetitive finding is on each floor of the six-story facility building.

7. The typical fire extinguisher cabinet in the newly built addition to the east and attached to the existing facility was noted to be left unlocked with door ajar allowing the fire extinguisher to be used as a mean of weapon to harm a patient and /or staff.

8. The typical wall and floor cabinets in the Craft room C-104 and work shop C-134 in the newly built addition have standard hardware installed in lieu of the require anti legit or recessed hardware to prevent the potential for patient harming self and the use for a tie-off.

Above items were confirmed by staff I at the time of observation.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated April 19, 2017.
K-0211
K-0311
K-0321
K-0345
K-0355
K-0362
K-0372
K-0374
K-0379
K-0921

Based upon observation and interview the facility failed to provide a sanitary environment in the kitchen prevent the transmission of foodborne and vectorborne communicable diseases. This deficient practice could potentially affect all inpatients, partial hospital program patients, and staff or visitors that consume food prepared from the kitchen. Findings include:

During the tour of the facility on 4/17/17 between 0900 and 1600 the following observations were noted:

1. Two operational fans were noted during the tour of the kitchen. One fan was noted to be placed near the cooking area and the second was noted at the discharge side of the dish washing machine. Both fans grille and blades exhibited visible lint and filth build-up on them. This is an indication that the kitchen ventilation system is either undersized and/or is experiencing end of life expectancy.

2. The floor next to the dishwasher and the pots and pans washing section of the kitchen was noted to be very wet and a puddle of water was noticed where the staff working path is, leading to a potential for slip and fall with possible serious injury to staff and a breeding ground for bacteria or mold.

3. The typical air supply diffuser in the kitchen area exhibited filth build-up (visible dirt) and discharge on the adjacent ceiling tiles. This is an indication that either the heating, ventilation, and cooling (HVAC) unit is filthy, duct line needs to be cleaned, and/or the air filter is much packed with filth and is not functional any longer.

Above items were confirmed by staff I at the time of observation.

Based on record review and staff interview, the hospital failed to insure that the psychiatric evaluations included acute and/or chronic non-psychiatric medical history for two (2) of 12 active sample patients (Patients C10 and E3). This results in the failure to assess the impact of an acute or chronic medical condition that may impact on current psychiatric presentation.

Findings include:

A. Record Review

1) Psychiatric evaluation of Patient C10 dated 7/21/16 had under "Current Medical Conditions: depakote dr 250 mg po tid, thorazine 100mg tid, haldol/benedryl[sic] prn for agitation."

2) Psychiatric evaluation of patient E3 dated 4/6/17 had under "Current Medical Conditions: (s/he) is very delusional, and when asked what is [his/her] medical problems, (s/he) said, "I am transgender."

B. Staff Interview

In a meeting with the Clinical Director on 4/18/17 at 3:00 p.m. and reviewing the above deficiencies the Clinical Director agreed with the deficiencies and further stated, "Not what I expect."

Based on record review and staff interview, it was determined that the Psychiatric Evaluations failed to include an inventory of patient's personal assets in descriptive, non-interpretative fashion for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, D8, D14, C10, C24, E3, and E8). This deficiency results in a lack of information to guide in developing a plan of treatment for the patient.

Findings include:

A. Record Review

1) Psychiatric Evaluation of patient A1 dated 10/26/16 had "Strengths for NRI: Attempting to realize one's potential, motivation and readiness for change."

2) Psychiatric Evaluation of patient A8 dated 3/8/17 had "Strengths for NRI: Assess of self-esteem/motivation/achiev." [sic]

3) Psychiatric Evaluation of patient A20 dated 4/4/17 had "Strengths for NRI: Attempting to realize one's potential, culture/spirit/relig/community involve." [sic]

4) Psychiatric Evaluation of patient A32 dated 3/21/17 had "Strengths for NRI: Attempting to realize one's potential, culture/spirit/relig/community involve." [Sic]

5) Psychiatric Evaluation of patient B3 dated 5/4/16 had "Strengths for NRI: Other".

6) Psychiatric Evaluation of patient B28 dated 9/22/16 had "Strengths for NRI: No strengths identified."

7) Psychiatric Evaluation of patient C10 dated 7/21/16 had "Strengths for NRI: Assess of self-esteem/motivation/achieve." [sic]

8) Psychiatric Evaluation of patient C24 dated 3/03/17 had "Strengths for NRI: Other."

9) Psychiatric Evaluation of patient D8 dated 10/18/16 had "Strengths for NRI: Other."

10) Psychiatric Evaluation of patient D14 dated 6/16/16 had "Strengths for NRI: Other."

11) Psychiatric Evaluation of patient E3 dated 4/6/17 had "Strengths for NRI: Other."

12) Psychiatric Evaluation of patient E8 dated 12/01/16 had "Strengths for NRI: No strengths were identified, school engagement."

B. Staff Interview:

In a meeting with the Clinical Director on 4/18/17 at 3:00 p.m. with the focus being a review of a sample of the deficiencies described in Section I, above, the Clinical Director agreed with the above deficiencies and further stated, "Not even a sentence, not what I expect."

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) clearly defined problem statements written in behavioral and descriptive terms. Specifically, the MTPs included problem statements with diagnoses, psychiatric jargon, and/or generic symptoms instead of specific individualized and descriptive clinical symptoms or behaviors based on the psychiatric evaluation and other clinical assessments for nine (9) of 12 active sample patients (A1, B3, B28, D8, D14, C10, C24, E3, and E8). These failures adversely affect clinical decision-making in formulating goals and active treatment interventions and result in fragmented treatment plans that are not comprehensive or individualized to patients' presenting psychiatric problems.

Findings include:

A. Record Review

1. Patient A1's MTP, dated 2/17/17, included the following psychiatric problem statements: "Psychosis, Mood problems and Impaired social interaction." These problems were diagnostic terms, non-specific, and not individualized statements. They were not stated in behavioral and descriptive terms that reflected the patient's clinical presentation as described on the psychiatric evaluation dated 5/4/16 such as, " ...thinks people are out to get [him/her], hears voices telling [him/her] people are against [him/her]. [s/he] blames other people stole [his/her] purse and took [his/her] checks."

2. Patient B3's MTP, dated 2/15/17, included the following psychiatric problem statements: "mood swings, delusions, non-compliance, victim of assault, seclusion/restraint due to assault." These problems were diagnostic terms, non-specific, and not individualized statements. They were not stated in behavioral and descriptive terms that reflected the patient's clinical presentation as described on the psychiatric evaluation dated 5/4/16 such as, " ... pt [patient] felt they were poisoning [him/her] through water and food, [s/he] was not sleeping well, [s/he] was depressed and had suicidal thoughts, over-dosed on insulin."

3. Patient B28's MTP, dated 3/28/17, included the following psychiatric problem statements: "psychotic paranoia, multiple substance abuse." These problems were diagnostic terms, non-specific, and not individualized statements. They were not stated in behavioral and descriptive terms that reflected the patient's clinical presentation as described in the psychiatric evaluation dated 9/22/16 such as, " ... hearing voice telling [him/her] we are going to kill you and became paranoid" and visual hallucinations of 'seeing the devil sitting in a chair telling me they are coming to kill me'..."

4. Patient D8's MTP, dated 4/16/17, included the following psychiatric problem statements: "homicide, mood change, psychosis, bipolar affective, non-compliance, patient needs to develop a routine of productivity and responsibility." These problems were diagnostic terms, non-specific, and not individualized statements. They were not stated in behavioral and descriptive terms that reflected the patient's clinical presentation as described on the psychiatric evaluation dated 10/18/16, such as, " ... 'I thought I was queen of London. I thought I was Hindu god. I was not sleeping and doing all the things and happy. Then I lost interest doing things. I was suicidal try to hang myself but did not do. Hear voices telling things [sic]'..."

5. Patient D14's MTP, dated 4/16/17, included the following psychiatric problem statement: "delusion, mood altered, cocaine abuse." This problem statement was non-specific, not individualized statements, and included diagnostic terms. There were no behavioral descriptors showing how this patient precisely manifested these problems. The problem statement was not stated in behavioral and descriptive terms that reflected the patient's clinical presentation as described in the psychiatric evaluation dated 6/16/16 such as, " ... 'Voices tell me that my parents are going to die. I think people watch me and are trying to kill me. They are looking at me and pick at me' ..."

6. Patient C10's MTP, dated 1/27/17, included the following psychiatric problem statements: "Legal problems." "Unspecified psychosis." "Mood disorder due to known physiological a condition unspecified." These problems were non-specific, not individualized, and included diagnostic terms or generalized statements. There were no descriptions regarding the patient's legal problems as identified in clinical assessments as described in the social work assessment dated 7/20/16 such as, " ... patient's mother reported that the patient did engage in a willful course of conduct involving repeated or continuous harassment ... cause [mother's name] to feel frightened, or intimated, or threatened ..." The problem statements identified also did not include any descriptions of this patient's symptoms of psychosis or mood disorder. There were no behavioral and descriptive information of these symptoms found in the psychiatric evaluation dated 7/21/16.

7. Patient C24's MTP, dated 3/9/17, included the following psychiatric problem statements: "Poor impulse control: as evidenced by increased psychosis leading to verbal/physical aggression." "Schizophrenia, paranoid, and subchronic [sic]." These problems included a generalized statement regarding impulse control without describing" "increased psychosis" and identifying the content of delusions or other thought disturbances that led to aggressive behavior. The problem statements failed to include any of the behavioral and descriptive information that reflected the patient's clinical presentation as noted in the psychiatric evaluation dated 3/3/17 such as, "[S/he] believes that police wants to arrest people to keep their jobs and make money out of people who got arrested. [S/he] still believes that police are to get him any time if they want."

8. Patient E3's MTP, dated 4/13/17, included the following psychiatric problem statements: "Legal problems, as evidenced by [him/her] on IST [Incompetent to Stand Trial for [his/her] charges." "Delusional disorder, with bizarre content, multiple episodes currently in acute episode." These statements were non-specific, not individualized, and included a diagnosis. The problems statements failed to include any behavioral or descriptive information regarding how this patient precisely manifested symptoms associated with the diagnosis or the content and behaviors associated with the patient's delusions. The problem statements failed to include any of the behavioral and descriptive information that reflected the patient's clinical presentation as noted in the psychiatric evaluation dated 4/6/17 and the social work assessment dated 4/7/17. In addition, there were no descriptions regarding the patient's legal problems as identified in clinical assessments.

9. Patient E8's MTP, updated 3/15/17, included the following psychiatric problem statements: "Poor decision making skills as evidenced by grandiose delusions, paranoid behavior, poor judgment, threatening behavior and non-compliance with treatment." "Schizoaffective disorder, bipolar type" "Substance Abuse" These problem statements were non-specific, not individualized, and included diagnoses. The problems identified did not include any descriptions regarding the content of the patient's delusions and how they affect his/her behavior and level of functioning. In addition, there were no behavioral descriptions regarding non-compliance with treatment or how the patient manifested symptoms associated with each identified diagnosis.

B. Interviews

1. During interview on 4/18/17 at 10:35 a.m. with the Director of Activity Therapy, psychiatric problem statements on Master Treatment Plans for active sample patients C10, C24, E3, and E8 were discussed. She did not dispute the findings that many problem statements were actually diagnoses, not individualized, and did not contain behavioral descriptions of each patient's psychiatric symptoms.

2. During interview on 4/19/17 at 11:15 a.m. with the Director of Nursing, psychiatric problem statements were discussed. She agreed with the findings and stated, "We have a lot of teaching to do with our staff about documentation. We need in-service for all clinical staff." When discussing problem statements with her staff, she noted, "I tell them that it is not individualized to just say delusion. They need to say, the content of the delusion."

3. During interview on 4/18/17 at 3:00 p.m. with the Clinical Director, psychiatric problem statements were discussed. The Clinical Director agreed with problems statements as "not individualized" and did not dispute above findings.

Based on record review, policy review, and staff interview, it was determined that the hospital failed to develop active treatment interventions that were specific and individualized to patients' needs. Specifically, interventions to be delivered by registered nurses were routine and generic nursing duties written as active treatment interventions for 12 out of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8). In addition, interventions to be delivered by activity therapy staff were non-specific and failed to identify an individualized focus of treatment for three (3) of 12 active sample patients (C10, C24, and E3) that were based on their assessed needs and interests. This failure results in staff being unable to provide direction, consistent approaches and focused treatment for patients identified problems.

Findings include:

A. Record Review

1. Nursing interventions in the treatment plan were generic and discipline specific roles versus individualized patient interventions based on assessed patient needs.

a. On Treatment Plan dated 2/17/17 for Patient A1, the new short-term goal was, "The patient will be able to verbalize two reasons for [his/her] aggression once a week in next 4 consecutive weeks by 02/27/16." The nursing intervention statement read as follows: "RN will meet with the patient weekly to provide teaching on this diagnosis and to educate the negative effects of having inappropriate mood. Patient continue to have labile mood and needs redirection from staff."

For the goal of, "The new short term goal is that the pt [patient] will talk in a realistic manner for 15 minutes once weekly over the next four consecutive weeks by 05/16/17," the nursing intervention statement read as follows: "RN will meet with the patient weekly to provide teaching on this diagnosis and medication related to the diagnosis. Patient encouraged to voice concerns in a calm/positive manner. Patient continues to have episodes of psychosis, patient will be praised for good effort." The intervention was a routine and normal nursing duty of assessing and/or managing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

b. On Treatment Plan dated 3/8/17 for Patient A8, for the goal of "Patient will be able to verbalize 2 benefits of taking medications for 10 minutes once a week by 4/12/17," the nursing intervention statement read as follows: "RN will include the patient in creating the teaching plan, beginning with establishing objectives and goals for learning about mental illness at the beginning stage." For the goal, "Patient will identify 2 triggers of substance abuse," the nursing intervention statement read as follows: "RN will convey attitude of acceptance, separating individual from unacceptable behavior and promote feelings of dignity and self-worth. RN will also encourage patient to attend assigned PSR groups." The intervention statement was a routine and normal nursing duty of assessing and/or managing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

c. On Treatment Plan dated 4/11/17 for Patient A20, for the goal "Patient will be able to verbalize [his/her] feelings and concerns without any anxiety or depression at least for 10 minutes once a week by 5/10/17," the nursing intervention statement read as follows: "Nursing: will meet with the pt and discuss benefits/side effects. Patient will be encouraged to express [his/her] feelings in a calm and positive manner when talking to staff." The intervention was a routine and normal nursing duty of assessing and/or managing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

d. On Treatment Plan dated 3/30/17 for Patient A32, it was stated that, "The new goal for the patient to be able to verbalize [his/her] concerns in calm, co-operative manner without any aggressive behaviors for 10 mts [minutes] twice a week by 6/20/17." The nursing intervention read as follows: "RN will meet with the patient 10 min weekly and as needed to assess current mood and approach the patient in a consistent manner in all interactions." For the goal of, "The revised goal for the patient to be able to make a reality based conversation without any psychotic symptoms for 15 mts [minutes] once a week by 6/20/17."

The nursing intervention statement read as follows: " During RN and patient weekly meeting RN will be direct, straightforward, and dependable. Whenever possible, elicit [his/her] feedback. Move slowly, with a matter- of- fact manner, and respond without anger or defensiveness to [his/her] hostile remarks." The intervention was a routine and normal nursing duty of assessing and /or managing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

e. On Treatment Plan dated 2/15/17 for Patient B3 the goal "Pt will have stable mood. Free of self-abuse or assaults," the nursing intervention statement read as follows: "Assigned RN will meet with the patient weekly in 1:1 session to assess thought process. RN will educate patient on current medication regiment and the importance of medication compliance. Patient will be encouraged to verbalize feelings and thoughts in appropriate. [sic]."

For the goal "Pt [Patient] will have reality oriented thoughts. Will refrain from assaulting others based on [his/her] delusions," the nursing intervention reads as follows: "assigned RN will meet with the patient in 1:1 session with focus on understanding disease process and the importance of medication compliance in controlling symptoms. Patient will be encouraged to interact with others in a reality based manner. Patient will be encouraged by all staff to attend and participate in all assigned PSR groups." The intervention was a routine and normal nursing duty of assessing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

f. On Treatment Plan dated 3/28/17 for Patient B28 the goal "Pt's behavior will be free of the effect of [his/her] paranoid delusions/ A. Hallucinations and [his/her] judgment relationship and mood become based on reality and no longer runs the street endangering self or others," the nursing intervention statements read as follows: "Assigned RN will meet with the pt for 10 minutes per week and will provide education regarding [his/her] diagnosis. The RN will assist the patient in identifying the symptoms that are related to [his/her] diagnosis such as utilizing for judgment [sic] and endangering [himself/herself] and others as well. The patient will be encouraged to take [his/her] medications as ordered and [s/he] will be educated on the uses and side effects of [his/her] medication. The patient will be encouraged to attend and participate in the scheduled PSR groups. The patient will be encouraged to verbalize [his/her] thoughts and feelings to staff." The interventions were routine and normal nursing duties of assessing and encouraging the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

g. On Treatment Plan dated 2/15/17 for Patient D8 the goal of "Patient will maintain stable mood," the nursing intervention statement read as follows: "Assigned RN will meet with patient weekly to assess thought process. Patient will be educated on current medication regiment and the importance of compliance. Patient will be educated on coping strategies and how to utilize them properly. All staff will encourage patient to attend assigned PSR groups and participate."

For the goal of, "Pt will maintain clear thinking," the nursing intervention reads as follows: "Assigned RN will meet with patient weekly to assess thought process and to educate on current medications. Patient will be provided with support and will be encouraged to verbalize concerns in a socially appropriate manner. Staff will assess for alteration in thoughts and provide reality orientation as needed." The intervention was a routine and normal nursing duty of assessing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

h. On Treatment Plan dated 4/16/17 for Patient D14 the goal "Pt will think clearly in a reality based manner," the nursing intervention statement read as follows: "RN will meet with patient weekly, for 20 minutes to educate the patient on [his/her] mental illness and to allow the patient to express [himself/herself]. Patient reoriented to reality as needed and educate patient on the importance of medication compliance to help alleviate symptoms. Patient will be encouraged to attend assigned PSR groups to learn coping skills that will help [his/her] to focus and give [his/her] the ability to handle [his/her] problems effectively in an appropriate manner." The intervention was a routine and normal nursing duty of assessing and encouraging the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

i. On Treatment Plan dated 1/27/17 for Patient C10 the goal "No aggressive/assaults for 8 weeks before going to court," the nursing intervention statement read as follows: "RN will meet with patient approx. 15 min weekly to educate the patient on [his/her] diagnosis of mood disorder. The RN will assess the client's experiences of distress and disability, identifying behavior, affect (e.g. mood swings, emotional overreactions, and encourage [him/her] to utilize effective coping strategies." The intervention regarding education failed to include whether the patient would be taught about his/her diagnosis in individual or group sessions. The latter intervention was a routine and normal nursing duty of assessing the patient rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

j. On Treatment Plan dated 3/9/17 for Patient C24 the goal "Patient prior to discharge will comply with medication and demonstrate effective coping skills when psychosis and frustrations demonstrate occurs as alternative to aggression," the nursing intervention statement read as follows: "[RN's name] will meet with patient for 10 minutes weekly and provide education on coping skills and encourage the patient to verbalize any concerns in a calm and positive manner. Nursing staff will monitor the patient's behavior and report any impulsive behavior ... The RN will provide education on [his/her] medications. This teaching will include action, side effect ..." The intervention statements regarding educating the patient about coping skills, and medications were non-specific and failed to identify which medication would be taught and whether the patient would be taught in individual or group sessions. The intervention regarding monitoring behavior was a routine and normal nursing duty rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

k. On Treatment Plan dated 4/13/17 for Patient E3, the goal "[Patient's name] will be free of delusions, and focus his thoughts on reality," the nursing intervention read as follows: " ... The RN will encourage [him/her] to verbalize concern in a calm, socially appropriate manner. The RN will assess [him/her] for signs of altered thought process and will help him with appropriate outlets for stress ..." The interventions regarding assessing behavior and encouraging the patient were routine and normal nursing duties rather than specific actions to be taken to assist the patient to achieve his or her treatment goals. In addition, the intervention failed to include whether contact with the patient would occur in individual or group sessions.

l. On Treatment Plan dated 3/15/17 for Patient E8, the goal "By discharge, pt. will make effective decisions as demonstrated by [his/her] response to a presenting situation," the nursing intervention statement read as follows: "RN will meet with patient on weekly basis to provide education on this diagnosis, reality orientation given, Patient [sic] encouraged to remove self from known cause of stress to control [his/her] aggressive and threatening behavior. Patient is also being encouraged to be compliant with [his/her] medication regimen ..." The intervention statements regarding educating the patient about his/her diagnosis was non-specific and failed to include whether this intervention would be delivered in individual or group sessions. The interventions regarding monitoring behavior and encouraging the patient were routine nursing duties rather than specific actions to be taken to assist the patient to achieve his or her treatment goals.

2. Activity Therapy interventions in the treatment plan were generic and discipline specific roles versus individualized patient interventions based on assessed patient needs.

a. On Treatment Plan dated 1/27/17 for Patient C10 the goal "Patient prior to discharge will comply with medications and display effective coping skills when frustrations and stressors occur. In addition voice reality oriented statements during interactions," the activity therapy intervention read as follows: "Patient will attend Engagement in Productive Activities 2 time weekly conducted by [Staff's name] C.T.R.S. with focus on demonstrating ability to complete assigned tasks. Voice daily goals and gain insight into productive life activities." This intervention statement was actually what the patient would be doing rather than specific actions that would be taken by the activity therapy staff to assist the patient to achieve his or her treatment goals. In addition, the intervention was non-specific and given numerous coping strategies, possible appropriate strategies were not identified that could be used by this patient based on assessed clinical needs.

b. On Treatment Plan dated 3/9/17 for Patient C24 the goal "Patient prior to discharge will comply with medications and display effective coping skills when psychosis and frustrations occur as alternative to aggression," the activity therapy intervention statements read as follows: "Patient will be scheduled for 1:1 sessions with Therapist 1 time weekly for 15 minutes. Fitness 3 times weekly for 40 minutes conducted by [Staff's name] C.T.R.S. Special Events 1 times per month for 60 minutes and Leisure Activities daily with focus on learning effective and anger management skills ..." These intervention statements were non-specific and not individualized. They included routine duties of scheduling therapeutic activities for the patient without specifying a clear focus of treatment for each activity and identifying coping and anger management skills that might be effective with this patient based on the patient's assessed needs and interests.

c. On Treatment Plan dated 4/13/17 for Patient E3 the goal "By discharge, [Patient's name] will demonstrate effective social interaction skills," the activity therapy intervention statements read as follows: "[Staff's name], CTRS will attempt to communicate with patient once per day, five days per week. The therapist will provide information about Activity Therapy programming as well as provide leisure materials that are appropriate for [his/her] living environment and that are acceptable with the safety structure of this hospital." These intervention statements were non-specific, not individualized, and failed to include a focus of treatment related to this patient psychiatric problem and treatment goal. The statement regarding providing information about the Activity Therapy programming was a routine activity staff duty provided for all patients.

B. Policy review

The policy issued 11/16/12 titled, "Individualized Plan of Services (IPOS) SOP number 261 states, "In accordance with applicable standards and regulations, WRPH will develop and implement individual plan of services which uses the person-centered planning processes to assure that services are provided based upon the condition and needs of the patient using the least restrictive modality." As stated in the policy there was an expectation of individualized patient centered interventions.

C. Staff Interviews

1. In discussion with Director of Nursing on 4/18/17 at 3:00 p.m., she agreed that the nursing interventions described under record review for patients B3, B28, D8, D14 were discipline specific role requirements and not interventions and modalities individualized to each patient's specific assessed needs.

2. In an interview with the Director of Activity Therapy on 4/18/17 at 10:40 a.m., she did not dispute the findings that some of the activity therapy interventions were non-specific and not individualized.

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

I. Ensure that all active treatment measures, such as individual active treatment activities, were provided for one (1) of four (4) active sample patients (E8) who were either unwilling or not motivated to attend assigned group treatment interventions identified on unit schedule and Master Treatment Plan (MTP). Although Master Treatment Plans and activity schedules included multiple group therapies, Patient E8 regularly and repeatedly did not attend many active treatment groups. There were no alternative individual therapeutic activities for this patient. In addition, the MTP was not revised to include alternative modalities, such as one to one intervention with clinical staff to achieve the patient's treatment goals identified on the MTP. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being delivered to them in a timely fashion, potentially delaying their improvement.

II. Ensure that active treatment interventions were provided on evenings and weekends for 12 out of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) and two (2) non-sample patients (E5 and E9). Specifically, only diversion type activities were available on the evening shift with limited participation by patients and there were no active treatment measures scheduled to be provided by registered nurses, social workers, and activity therapy staff during the week of April 8 through 16, 2017 as this was a program evaluation week. This resulted in no active treatment at all on weekdays and the weekends from April 8 through 16, 2017. These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their improvement, and slowing progress.

Findings include:

I. Failure to provide alternative active treatment modalities

1. Patient E8 was admitted on 11/29/16. The Psychiatric Evaluation dated 12/1/16, stated, " ...carry the diagnosis of Schizoaffective disorder ... had been noncompliant in the community ... Persistent delusions of grandiosity 'I was in marine corps and posted to Pakistan', also noted in record ... [s/he] has had 6 admits since [s/he] was discharged from [name of facility] in 3/2016 and presents with paranoid delusions, hallucinations, agitation and no insight, impaired judgment and non compliance."

2. Patient E8 was observed in bed on 4/18/17 at 9:20 a.m. with a blanket over his/her head. S/he was assigned to attend a 9:30 a.m. psychosocial rehabilitation (PSR) group titled, "Balancing emotions (Anger Management)" that was scheduled off the unit. MHT1 (Mental Health Tech #1) encouraged the patient to get out of bed and attend the group session but s/he refused. MHT1 reported that the patient had not been going to many groups.

3. In a discussion on 4/18/17 at approximately 9:25 a.m., when a group titled, "Balancing" was about the start in the Center for Activity and Rehabilitation Therapy (CART). SW3 (Social Worker#3) stated that the patient does not attend group often. She stated that she does not provide alternative one to one contact with the patient to provide handout information used during the group sessions and said, "[Social worker's name] meets with him monthly" but admitted that this patient did not get regular one to one contact to receive information presented during this assigned group.

4. The treatment modalities identified on patient E8's MTP, dated 3/15/17 included the following interventions:

a. For the problem of, "Poor decision making skills as evidenced by grandiose delusions, paranoid behavior, poor judgment, threatening behavior and non-compliance with treatment."

RN Intervention: "RN will meet with patient on weekly basis to provide education on this diagnosis [sic], reality orientation given, patient encouraged to remove self from know cause [sic] of stress to control [his/her] aggressive and threatening behavior. Patient is also being encouraged to be compliant with [his/her] medication regimen while here at the hospital and after discharch [sic] to the community to avoid recurrent hospitalizations."

RN will meet the patient two (2) times weekly in PSR group to provide information about everyday living skills ... to help patient achieve personal goals.

AT Intervention: " ...CTRS will see patient three time per week for 60 mins [minutes] each in the Activity Therapy program Coping Skills [sic]. During these sessions the therapist will offer a variety of coping strategies and encourage patient to participate in worksheets assignments and group discussion. The therapist will also provide guidance and redirection when patient loses focus and attempts to not attend scheduled sessions.

SW Intervention: " ... LMSW will facilitate Balancing Emotions and Behavior PSR every Tuesday and Thursday from 9:30 - 10:30 a.m. Social worker will educate patient regarding techniques to manage [his/her] intense emotions, balance mood, and display safe and appropriate behavior. Techniques taught will include assertive communication skills, coping skills, and positive self-talk. Patient will be provided with positive reinforcement for attendance and appropriate participation.

b. For the psychiatric problem "Schizoaffective disorder, bipolar type":

SW Intervention: "The Social Worker will meet with the patient one to one for individual supportive therapy for 20 minutes 1x a week. In these sessions, the Social worker using reality orientation will educate the patient on the importance of being consistent with [his/her] treatment recommendations. The social worker will educate the patient to better manage [his/her] mental illness i.e. stress management, maintaining consistent schedule, developing coping skills ..."

c. For the psychiatric problem "Substance Abuse":

MD Intervention: "Will be seen weekly and educated about [his/her] illness, therapy provided, motivational interviewing done and explained how street drugs and alcohol can cause worsening of [his/her] mental health and cause relapses and readmissions to hospital as well as how it effects [his/her] physical health ..."

RN Intervention: "RN meets with patient weekly to provide teaching on this diagnosis, Patient educated on the detriments of substance abuse on [his/her] overall health and wellbeing ..."

SW Intervention: " ... LMSW will conduct Putting It Into Practice PSR group M-W-F from 3:00 PM - 3:45 PM. The group will enhance the recovery process by assisting the patient with practice sessions, promoted through the use of worksheets, role play vignettes ... other CBT [Cognitive Behavioral Therapy] learning tools."

"The Social Worker will meet with the patient one on one for twenty minutes 1x a week for individual supportive therapy. In these sessions, the social worker using reality orientation will educate the patient on the detrimental effects of substance abuse and how it relates to [his/her] mental illness. The patient will identify one coping skill to avoid substance abuse."

5. A review of progress notes regarding individual (one-to-one) treatment modalities on the MTP assigned to registered nurses and the social worker revealed the following:

a. Registered Nurses - There was no treatment notes showing that registered nurses met with the patient to provide education regarding his/her diagnosis, medications, substance abuse that reflected descriptive information about specific topics discussed, specific medications taught, or detriments of substance abuse discussed. In addition, there was no documentation regarding how the patient responded during individual sessions, including level of participation, level of understanding, behaviors observed, and specific comments made by the patient.

b. Social Worker - There was no treatment notes showing that the social worker met with the patient to provide supportive therapy for 20 minutes once per week that documented descriptive information about specific topics discussed about being consistent with his/her treatment recommendations and specific educational topics discussed regarding stress management, developing coping skills, or detriments of substance. In addition, there was no documentation regarding how the patient responded during individual sessions, including level of participation, level of understanding, behaviors observed, and specific comments made by the patient.

6. The "PSR [Psychosocial Rehabilitation] Group Assignments" Sheets revealed the following groups assigned and progress notes revealed the following non-attendance by Patient E8:

a. Monday, Wednesday, and Friday 9:30 - 10:30 a.m. - "Coping Skills.

A review of the "Patient Attendance" Sheets revealed that Patient E8's non attendance was as follows: February 2017- did not attend 4 sessions out of 10 scheduled [excluded two holiday]; March 2017 - did not attend 11 sessions out of 14 scheduled [No national holidays]; and April 2017 did not attend 5 sessions out of 7 scheduled [excluded one holiday] Note: (1)Facility data showed that patient E8 did not attend 11 out of 20 sessions. However, these data did not count groups not held when staff was not available to conduct the group]. (2)The Director of Activity Therapy was unable to locate the "PSR End of Cycle" for the period covering November 2016 through January 2017. Therefore, there was limited information regarding the patient's attendance in this group. Three progress notes dated 12/22/16, 1/5/17, and 1/23/17 were found during this period reporting that the patient did not attend the coping skills group. (3)There was no documentation found in the electronic medical record showing that alternative active treatment measures were implemented for this patient.

b. Tuesday and Thursday 9:30 - 10:30 a.m. - Balancing Emotions (Anger Management)."

A review of progress revealed the following non-attendance in group treatment: A progress note dated 4/4/17 and 4/6/17 noted, "Patient refused to attend group despite multiple prompts from staff." Progress note dated 4/7/17 noted, "Patient arrived at group about ten minutes late, sat in room for 15 minutes and abruptly walked out ..." The "PSR End of Cycle" progress note for the period covering November 2016 through January 2017 documented that the patient did not attend any group sessions at all. There was no documentation found in the electronic medical record showing that alternative active treatment measures were implemented to address information provided during group sessions.

c. Monday, Wednesday, and Friday 3:00 - 3:45 p.m. - "Putting it Into Practice - Part 4 (Substance Abuse)."

A review of progress notes revealed the following non-attendance in group treatment: Progress notes dated 4/3/17 and 4/6/17 reported the patient refused to attend group sessions. Information provided by the Director of Activities revealed from February through April 18, 2017, the patient did not attend 19 of 27 group sessions. There was no documentation found in the electronic medical record showing that alternative active treatment measures were implemented to address information provided during group sessions.

d. Tuesday and Thursday 3:00 - 3:45 p.m. Personal Growth & Development."

A progress note dated 4/6/17 reported, "Patient refused to attend and participate in group discussion despite being encouraged by staff." The PSR End of Cycle Summary dated 4/12/17 noted, "The goal stated in the treatment plan has not been met. During the past 90 days the patient attended 11/18 [sic] sessions." There was no documentation found in the electronic medical record showing that alternative active treatment measures were implemented to address information provided during group sessions.

7. A review of Patient E8's MTP updated 3/15/17 revealed that despite this patient's low attendance and lack of participation in assigned group treatment sessions, the MTP had.

8. The following interviews were conducted regarding Patient E8's participation in active treatment:

a. During interview on 4/17/17 at 2:00 p.m., Patient E8 admitted that s/he spends a lot of time in bed and stated, "I don't like to attend groups. Groups are pointless. They are boring, except for [staff's name] group." When asked about medications and coping skills, the patient stated no one had discussed [his/her] medications or coping skills. The patient reported that no written information had been provided regarding medication and coping skills.

b. During interview on 4/17/17 at 2:30 p.m., RN5 confirmed that Patient E8 did not attend many groups. RN5 admitted that alternative active treatment measures were not offered when the patient did not attend group treatment sessions.

c. During interview on 4/18/17 at 10:35 a.m. with the Director of Activity Therapy, Patient E8's lack of participation in the active treatment program was discussed. She did not dispute the finding that alternatives were not being made available when this patient refused to attend group treatment sessions. When asked about alternative individual sessions and if written information or handouts used during groups were given to the patient, she stated, "We are not doing that. We don't have the staff [activity therapy] to provide individual sessions."

II. Failure to provide active treatment interventions on evenings and weekends

A. Record review

1. On 4/18/17 at 3:45 p.m. the Director of Nursing was asked to provide documentation of weekend therapeutic group activities. She was only able to provide a summary of patients overall compliance with PSR groups none of which was specific to weekend group activities.

2. Interoffice memorandum dated 3/27/17 titled, "Evaluation week presentation schedule" included groups that were informational in focus and not therapeutic in nature. There was only one group per day per unit that was scheduled. Topics include: safety video, recipient rights, infection control, [name of city] fire video. These group topics were not individually assigned to patients, nor were they related to the psychiatric symptoms or problems for each patient in the sample. Those listed above were four (4) of the five (5) groups provided from April 8 through April 16, 2017.

3. The evening and weekend schedule dated 1/29/17 through 4/29/17 for each unit listed the following weekend activities that were to be run by the nursing staff. Unit R2 Saturday group was a walking group at 7:30 p.m. and Sunday group was table top games 7:30 p.m.; Unit R3 Saturday group was table top games at 6:00 p.m. and Sunday group was table top games at 6:15 p.m.; Unit R4 Saturday group was table games at 7:30 p.m. and Sunday group was music appreciation at 7:30 p.m.; Unit R5 Saturday group was table top games at 7:30 p.m. and Sunday group was table top games at 7:30 p.m.; Unit R6 Saturday group was exercise for life at 7:30 p.m. and Sunday group was movie night at 8:30 p.m.

B. Patient interviews

1. During interview on 4/17/17, Patient D8 reports, "The weekends are boring, I walk around the unit for up to 2 hours a day, I invite staff to play cards with me, some patients sleep all day, but I cannot sleep during the day, there are no groups."

2. During interview on 4/18/17 at 1:30 p.m. in the CART (Center for Activities and Rehabilitation Therapy), patient E5 reported, "There are no groups on the weekends. I sleep most of the time and rest."

3. During interview on 4/18/17 at 1:35 p.m. in the CART, patient E9 reported, "There are no groups on Saturday or Sunday. There is quiet time and people nap a lot." He also reported that the week of April 9-14, 2017 was "evaluation week, there was just one group per day, and stated, "I got credit for 3 groups. We watched a video on fire safety, but I saw it a lot of times before, so I played cards."

C. Staff interviews

1. During interview on 4/18/17 at 3:00 p.m. with the Director of Nursing, she stated, "The weekend activities are very casual such as trivia, exercise, current events." She indicated there are no attendance sheets for these activities. She stated, "I wasn't aware that activities therapists were not scheduled on the weekend providing group treatments." She reported that, "Nurses aren't able to run groups on the weekends as they are busy providing showers, milieu management, and monitoring visitors." When informed that the patients report no formal activities over the weekend, she said, "I believe that."

2. During interview on 4/19/17 at 9:15 a.m., the Director of Nursing stated, "Patient's aren't assigned to weekend groups, they are open to everyone. The weekend and evening groups are not part of the core PSR schedule."

3. During interview on 4/17/17 at 10:30 a.m., SW1 reported that, "On the weekends, the nurses run social groups such as cards and music, the gym is open for activities if the nursing staff is able to bring patients there."

4. During interview on 4/18/17 at 12:00 p.m., OT1 reported that during the week of April 8-16, 2017, the PSR (Psychosocial Rehabilitation Program) was being evaluated and no therapeutics groups occurred. She reported, "One group per day that was instructional on topics such as [name of city] fire video, recipient rights, safety video, and infection control occurred instead."

5. During interview on 4/17/17 at 2:40 p.m. in the CART workshop, AT1 reported, "There is not any activities therapy programming on the weekend and that all the activities therapy staff work Monday through Friday."

6. During interview on 4/17/17 at 11:00 a.m., RN1 reported that, "The week of April 9-14, 2017 was a program evaluation week, and patients don't have much to do that week."

7. During interview on 4/18/17 at 1:50 p.m., AT2 reported, "There are no CART groups on the weekend, that the CART is accessible to the RNs on the weekend, but I'm not sure if it's used or not."

D. Policy review

The policy issued 11/16/12 titled, "Individualized Plan of Services (IPOS) SOP number 261" stated, "In accordance with applicable standards and regulations, [Facility's name] will develop and implement individual plan of services which uses the person-centered planning processes to assure that services are provided based upon the condition and needs of the patient using the least restrictive modality." As stated in the policy there was an expectation of ongoing treatment while the patient is hospitalized.

Based on observation, interview, and record review, the facility failed to ensure the deployment of adequate numbers of qualified staff to provide active treatment to patients.

Specifically, the facility failed to:

I. Deploy an adequate numbers of clinical staff to meet the needs of patient for 12 out of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) and two (2) non-sample patients (E5 and E9) on evenings and weekends. Specifically, only diversion type activities were available during evening hours with limited participation by patients. Registered nurses, social workers, and activity therapy staff provided no scheduled active treatment interventions at all on evenings and weekends. In addition, there were no scheduled active treatment interventions provided patients during the week of April 8 through 16, 2017 as this was a program evaluation week. This resulted in no scheduled active treatment at all on weekdays and the weekends from April 8 through 16, 2017. These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their improvement, and slowing progress. (Refer to B125 -II).

II. Ensure that sufficient active therapy staff was deployed to plan and implement a structured therapeutic activities program for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) on evenings and weekends. Specifically, only diversion type activities were offered by activity therapy on evenings and weekends. There were no structured therapeutic activities and active treatment interventions offered by active therapy staff on evenings and weekends. The lack of structured active treatment results in patients having insufficient therapeutic activities to assist in their recovery and psychiatric treatment. (Refer to B158).

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

I. Ensure that active treatment interventions were provided on evenings and weekends for 12 out of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) and two (2) non-sample patients (E5 and E9). Specifically, only diversion type activities were available on the evening shift with limited participation by patients and there were no active treatment measures scheduled to be provided by clinical staff during the week of April 9 through 14, 2017 as this was a program evaluation week. This resulted in no active treatment at all on weekdays and the weekend from April 8 through 16, 2017. These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their improvement, and slowing progress. (Refer to B125-II)

II. Ensure that the Clinical Director monitored and took the needed corrective actions to ensure that clinical staff members were deployed to provide alternative active treatment interventions for one (1) of 12 active sample patients (E8) and active treatment intervention on evenings and weekends for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, E3 and E8) and two (2) non-sample patients (E5 and E9). These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their successful improvement, and slowing progress. (Refer to B144-IV & V).

III. Ensure that the Director of Nursing monitored and took the needed corrective actions to ensure that registered nurses were deployed to provide alternative active treatment interventions for one (1) of 12 active sample patients (E8) and active treatment intervention on evenings and weekends for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, E3 and E8). These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their improvement and slowing progress. (Refer to B148-II & III).

IV. Ensure that sufficient active therapy staff was deployed to plan and implement a structured therapeutic program for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) on evenings and weekends. Specifically, there were no structured therapeutic activities and active treatment interventions offered by active therapy staff during evening hours and on weekends with only diversion type activities were being offered. Therefore, there were no scheduled active treatment interventions provided to address and assist patients to alleviate the identified problems and needs on evenings and weekends. This failure potentially delays treatment effectiveness and deprives patients of important individualized and structured therapeutic activities to assist them with recovery and improvement in their symptoms of mental illness. (Refer to B158).

Based on record review and staff interview, the Clinical Director failed to adequately monitor and evaluate the quality of care provided to patients at the facility. Specifically, the Clinical Director failed to ensure that:

I. The Psychiatric Assessments included acute and/or chronic non-psychiatric medical history. (Refer to B112).

II. The Psychiatric Assessments included assessment and documentation of patients' personal assets. (Refer to B117).

III. The MTP's included clearly defined problem statements written in behavioral and descriptive terms. (Refer to 119).

IV. Active Treatment activities including alternative treatment interventions were provided to all patients (Refer to B125-I), as well active treatments were provided during evenings, weekends, and Program Evaluation weeks. (Refer to B125-II).

V. Ensure that the Clinical Director monitored and took the needed corrective actions to ensure that clinical staff members were deployed to provide alternative active treatment interventions for one (1) of 12 active sample patients (E8) and active treatment intervention on evenings and weekends for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) and two (2) non-sample patients (E5 and E9). (Refer to B136 and B139).

Based on record review, policy review, and interview, it was determined the Director of Nursing failed to monitor to:

I. Ensure that the treatment plan delineated individualized nursing interventions for 12 of 12 sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8). Specifically, interventions to be delivered by registered nurses were routine and generic nursing duties written as active treatment interventions. This failure results in nursing staff being unable to provide direction, consistent approaches and focused treatment for patients identified problems. (Refer to B122).

II. Ensure that all active treatment measures, such as individual active treatment activities, were provided for one (1) of four (4) active sample patients (E8) who were either unwilling or not motivated to attend assigned group treatment interventions identified on unit schedule and Master Treatment Plan (MTP). Failure to ensure patients' participation in active treatment modalities negates the clinical effectiveness of their treatment goals, potentially delaying successful improvement. (Refer to B125 -I).

III. Ensure that active treatment interventions were provided on evenings and weekends for 12 out of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8) and two (2) non-sample patients (E5 and E9). Specifically, only diversion type activities were available on the evening shift with limited participation by patients and there were no active treatment measures scheduled to be provided by registered nurse during the week of April 8 through 16, 2017 as this was a program evaluation week. This resulted in no active treatment at all on weekdays and the weekend from April 8 through 16, 2017. These failures result in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying their improvement and slowing progress. (Refer to B125-II).

Based on observation, record review, and interview, the facility failed to deploy sufficient staff to plan and implement a structured therapeutic activities program for 12 of 12 active sample patients (A1, A8, A20, A32, B3, B28, C10, C24, D8, D14, E3, and E8). Specifically, there were no structured therapeutic activities and active treatment interventions offered by active therapy staff during evening hours and on weekends for a patient population ranging in age from 18 through 65 years old and over. Only diversion type activities were being offered this patient population. Therefore, there were no scheduled active treatment interventions provided to address and assist patients to alleviate identified problems and needs on evenings and weekends. This failure potentially delays treatment effectiveness and deprives patients of important individualized and structured therapeutic activities to assist them with recovery and improvement in their symptoms of mental illness.

Findings include:

A. Observations

During observation on 4/18/17 at 9:35 a.m., the surveyor observed a group titled, "ADL" that was attended by active sample patient E3. RN6 conducted the group and the group room had 17 patients attending. One patient asked, Where is [activity therapy staff's name]? RN6 stated that the staff had not arrived yet. It was explained that the room had a divider to makes it two rooms. One side of the room was for a group scheduled titled, "Cognitive Stimulation" held from 9:30 a.m. to 10:30 a.m. The other side of the room was for those patients attending the group titled, "ADL" also held from 9:30 a.m. to 10:30 a.m. At approximately 9:50 a.m., the patients assigned to the other group were asked to leave the group room and were taken to the gymnasium. The Director of Activity Therapy who was in the hallway reported that the activity therapy staff assigned to do the group would not be available until noon and stated, "I don't have anyone to cover for him."

B. Report Review

1. A review of the five (5) unit schedules for the period 1/30/17 through 4/28/17 revealed that group therapeutic Activities were scheduled and assigned on all five (5) units as follows:

a. The Monday through Friday Programming was scheduled from 9:30 a.m. to 10:30 a.m. in the Center for Activity and Rehabilitation Therapy (CART) and on the unit; from 1:30 p.m. to 2:30 p.m. off unit with very few patients assigned to attend; from 2:45 - 3:45 p.m. with very few patients assigned to attend; and from 3:00 - 3:45 p.m. The scheduling sheets revealed that most patients were assigned from 9:30 - 10:30 a.m. and from 3:00 - 3:45 p.m. and showed that most patients received approximately two (2) hours of programming Monday through Friday. One unit R6 only had the CART morning programming available two times per week on Tuesdays and Thursdays, which reduced the number of therapeutic activities for this patient population.

b. The evenings and weekends programming was scheduled at 6:15 p.m. for Unit R3; at 7:30 p.m. for Units R4, R5, and R2; and at 8:30 p.m. on Unit R6. Except for "Medication Teaching" scheduled Mondays and Wednesdays on Unit R2, with two patients assigned, activities were not active treatment interventions to address and assist patients' to alleviate psychiatric problems and symptoms. The other activities on the schedule were mostly diversion type such as table games, movie night, and music appreciation open to all patients and only a few patients actually assigned to participate in activities. There were no patients assigned at all on weekends.

2. A summary report of the active treatment provided in the CART program for the first quarter (November 2016 through January 2017), highlighted problems with low group attendance, lack of documentation by activity therapy staff, and group leaders being absent. This report revealed that the "Coping Skills" Group scheduled on Unit R2 and conducted by activity therapy staff had only a 56% attendance rate. This report noted, "4 pts [patients] did not achieve goal due to low attendance and/or participation. Two other patients not identified in the chart review did not have End of Cycle Summaries, and one had no PSR documentation." Another active treatment group assigned to activity therapy titled, "Communication Skills" and scheduled on Unit R3 had only a 29% attendance rate. The report noted, "Patient attendance to groups continues to be an ongoing problem for some. If they do not attend, it will difficult for them to achieve their goal."

C. Interviews

1. In an interview on 4/17/18 at 11:10 a.m., Patient C24 stated that there was not much to do on Saturday and Sunday and reported, "I spend my time in my room in bed."

2. In an interview on 4/18/17 at 10:35 a.m. with the Director of Activity Therapy, the lack of therapeutic activities available on evenings and weekends was discussed. She agreed that currently there was not enough activity therapy staff to provide evening and weekend active treatment programming. She stated that she was aware that this was cited by CMS during the last survey and admitted, "We still don't have activities on weekends." She reported that initially they had assigned activity therapy staff on weekends but stated, "We had to discontinue because the Monday through Friday program was suffering." She reported, "There was no additional staff employed when they opened the new building [Center for Activity Rehabilitation Therapy]." She reported, "Currently, I am unable to cover for absences because four staff are covering the evening activities. I have concerns about this because of the low attendance in evening activities."