HospitalInspections.org

Based on the review of policy and procedure, facility documents, observation, and interview, it was determined that the facility failed to ensure:

(A-0386) a nurse executive was appointed to oversee the management of nursing services provided by the facility;

(A-0392) an acuity plan was established, documented, and implemented that included a method to establish the types and numbers of nursing personnel required in the hospital, assessments of patient need to be provided by a registered nurse, policies for steps to obtain necessary nursing personnel to meet patients' acuity needs, and assignments for patient care according to an acuity plan; and

(A-0398) new staff received orientation and training.

The cumulative effect of these systemic practices resulted in the facility's failure to meet the requirement for the Condition of Participation in Nursing Services, which poses a potential risk to the health and safety of patients if nursing services are not organized and have oversight by a director that ensures appropriate delivery of care and quality of staffing.

Based on observation, facility documents, and interviews, it was determined that the facility failed to ensure a nurse executive was appointed to oversee the management of nursing services provided at the facility. This deficient practice poses a risk to patient safety if a nurse executive is not present to ensure nursing services are provided in a safe and effective environment.

Findings include:

Observations revealed during a tour of the facility of a bulletin board posted in the hospital lobby, which listed the name of the current hospital administrator and the medical provider of the facility. But, the position for director of nursing stated "TBD".

A review of the facility organizational chart on 10/17/2022 revealed that the director of nursing position for the hospital is vacant.

The facility staffing roster revealed the facility does not have a director of nursing on staff.

The job description titled "Director of Nursing" revealed: "...Position Summary...The Director of Nursing is responsible for the management of ChangePoint Psychiatric Hospital's nursing department and for the direction and supervision of all nursing functions and activities. The Director of Nursing is also responsible for the quality of customer care and monitors that sufficient and competent personnel carry out the functions of nursing services. Administrative responsibilities include planning and managing nursing services, evaluation of staff, and resource allocations...Position Requisites...Required: Bachelor's Degree from an accredited Nursing school or an Associate's Degree from an accredited school...Current Arizona RN license...Four years of recent clinical experience including one (1) year of administration...."

Employees #15, 19, and 20 confirmed in an interview conducted on 10/17/2022 that the facility currently does not have a director of nursing services. Both employees confirmed that the prior [director of nursing services] "left a couple of months ago"] and no replacement has been established by the facility. Employees #19 and 20 confirmed that they report to the [hospital administrator] in regard to nursing services.

Employees #2 and 15 confirmed on 10/18/2022 that the facility does not have a current director of nursing services to oversee the provision of nursing services at the facility. Employee #2 did not provide a projected hiring date for a director of nursing. But stated that the facility has been without a director of nursing services for ""a couple of months" and that nursing services are overseen by the [hospital administrator], who is not a nurse.

Based on the review of facility documents and interviews, it was determined that the facility failed to ensure an acuity plan was formulated, established, documented, and implemented as follows: (1) a method to establish the types and numbers of nursing personnel required, (2) the type and number of personnel to provide assessments of the needs of the patient population, (3) policies on how to obtain the necessary number of nursing personnel to safely care for the patients, and (4) on how to assign types and number of personnel to provide proper patient care as outlined in an acuity plan. This deficient practice poses a risk to the health and safety of patients if an acuity plan is not formulated, established, documented, and implemented on how staffing will meet each patient behavioral care needs.

Findings include:

The hospital nursing acuity plan and policies were requested for review. None were provided.

Employees #19 and 20 confirmed in an interview conducted on 10/17/2022 that the facility does not use an acuity plan or have policies to determine the types and numbers of staff required, who assesses the patient acuity needs, how assignments are made based on patient care needs, or how to obtain additional staff if needed to meet the higher level of acuity needs of patients.

Employees #15, 19, and 20 confirmed that RNs and LPNs may be assigned to the "Crisis Stabilization Unit" during their assigned shifts in the hospital, which is a separate licensed facility or an OTC located in another area of the hospital.

Employees #1 and 2 confirmed on 10/18/2022 that the facility does not have an acuity plan that addresses the numbers and types of personnel, assessments based on acuity needs of patients, staffing patterns based on patient acuity, or how the facility obtains an additional staff to meet higher levels of patients' acuity needs.

Based on the review of personnel files and interviews, it was determined that the facility failed to ensure new staff received orientation and training. This deficient practice poses a potential risk of staff not obtaining adequate and appropriate training to provide safe patient care.

Findings include:

Employees #4, 5, 6, 7, 9, 13, 17, 18, 19, 20, and 21's personnel files were reviewed and all files were found to be missing evidence of facility-specific new employee orientation or documentation of competencies prior to providing services.

Employee #16 confirmed on 10/19/2022 that the above-listed employees' personnel files each contained a "New Employee Orientation Schedule" form. However, Employee #16 confirmed that this is not a facility-specific orientation but rather occurs offsite at a corporate office and is a general overview of the company and HR onboarding requirements. Employee #16 further confirmed that none of the personnel files contained documentation of established competencies by the facility prior to providing patient care services or that staff received ongoing training specific to the care of the patient population.

Based on the review of policy and procedure, facility documents, observation, and interviews, it was determined that the facility failed to ensure:

(A-1687) behavioral health professionals, therapists, and counselors were staffed to provide the scope of services listed in the hospital's program description;

(A-1690) a licensed professional provided clinical oversight and supervision to BHTs (behavioral health technicians), BHPPs (behavioral health paraprofessionals), and nursing personnel;

(A-1700) the hospital had a director of psychiatric nursing services to oversee the management of nursing services provided at the facility;

(A-1715) a director of social services was employed by the facility; and

(A-1716) the facility's only social worker had a degree in social work or had another social worker or director of social services with a master's degree in social work or qualified by education and experience in the social services needs of the mentally ill.

The cumulative effect of these systemic practices resulted in the facility's failure to meet the requirement for Condition of Participation for Special Staff Requirements for psychiatric hospitals, which poses a risk to the health and safety of patients if the psychiatric hospital is not well organized and has appropriate directors, licensed staff, and mental health workers to oversee and deliver care.

Based on the review of facility documents, personnel files, and interviews, it was determined that the facility failed to ensure adequatenumber of behavioral health professionals, therapists, and counselors were staffed to provide the scope of services listed in the hospital's program description. This deficient practice poses a potential risk that patients are not able to receive comprehensive psychiatric care at the facility.

Findings include:

The job description titled "Social Serviced Director" revealed: "...This position provides assessment and discharge services for patients, families and involved agencies. Provides coordination and communication with ChangePoint's clinical outpatient staff, medical service staff, and other community agencies and medical facilities. This position will be responsible for supervising a staff of the Social Services Department...Works in coordination with Provider, Nursing, and Social Worker...Participates in the Performance Improvement processes...Provides supervision to assigned staff...Qualifications and Experience Required: Master's Degree in Social Work or equivalent combination of education and experience...Must be certified under A.R.S. Title 32, Chapter 33 or Nationally recognized credentialing...."

The job description titled "Social Worker" revealed: "...Qualifications and Experience Required: Behavioral Health Technician (BHT)...Preferred: Behavioral Health Professional (BHP)...."

The job description titled "BHP Therapist" revealed: "...The BHP Therapist provides assessment and performs as an assigned clinician and case manager, treatment, and related clinical activities to the clinic population with psychiatric diagnoses...Provides adequate assessment, crisis service, and psychotherapy using customer, family, and group modalities...development, implementation, and submission of the treatment plan...Qualifications and Experience Required: Master's Degree in Social Work, Counseling or Psychology, or related fields...Licensed by the Arizona Board of Behavioral Health Examiners or other acceptable state board..."

The document titled "Changepoint Psychiatric Hospital Functional Program Description/Clinical Service Plan" revealed: "...The hospital serves adults who are 18 years of age or older and who typically present with substance abuse, mental health, serious mental illness, and/or co-occurring disorders...ChangePoint Psychiatric Hospital is a 116-bed Level 1 Specialty Psychiatric Hospital licensed to provide acute inpatient psychiatric treatment and detoxification (moderate intensity) services...The hospital provides inpatient psychiatric services to residents of Northeast Arizona whose symptoms, acuity, and medical status meets admission criteria on either a voluntary basis or involuntary basis as an evaluation agency for Navajo and Apache County Superior Court...ChangePoint Psychiatric Hospital adheres to the following Principles of Practice...To inform members of their rights at the hospital...To involve the member and their family/significant others in the development of treatment goals, and work collaboratively in achieving those goals while they are in the hospital...continued stay criteria include: ...Must continue to need the same level of care to resolve any of the admission criteria...Lower level of care required to safely and effectively meet the clinical needs of the member is not currently available...Must continue to accept voluntary treatment within the hospital or be under a court order...Scope of Services Proved and Modalities Offered...The overall service delivery system and its components are based on best-practice guidelines issued by the American Psychiatric Association. any variances from these guidelines are noted in the clinical record. Internal monitoring of services to determine the degree of compliance is conducted on an ongoing basis by Utilization/Quality Management review of the clinical record...ChangePoint Psychiatric Hospital can provide the following services: ...Assessment and referral...Psychiatric evaluation and services...Nursing Care...Social Services...Group, family, and individual...counseling...Involuntary court-ordered services (Title 36)...Social Services: These services are under the direction of a Social Worker with graduate training and hospital experience and are proved by Behavioral Health Professionals, Behavioral Health Technicians, and assisted Paraprofessional Psychiatric Aides...Social Services partners with the Treatment Team to provide treatment planning; discharge planning, which begins upon admission based on a discharge needs assessment; family meetings; case management...counseling/psychotherapy...Counseling services: Counseling services primarily use a cognitive-behavioral approach involving individual, group, or family involvement and are proved approximately 3 hours per week, per member...Individual counseling: Sessions are conducted by qualified licensed staff and/or psychiatrists and are used to engage the member in the completion of the initial assessments, develop and evaluate the progress of treatment plan goals and objectives, discuss appropriate treatment modalities, and process and resolve problems of a short term nature...Family counseling: Sessions, conducted by qualified licensed staff...ROLES RESPONSIBILITIES, AND SUPERVISION OF PROFESSIONAL STAFF...Hospital Administrator: Serves as the Administrative Director for the psychiatric hospital...In the absence of the Administrator, the Director of Nursing assumes this role...Director of Nursing: Administrative nurse responsible for the hiring (in conjunction with the Hospital Administrator), training, and supervision of the Nursing Department staff, which includes RNs, LPNs, and PPAs. The Director of Nursing is responsible for maintaining appropriate staffing at all times for the inpatient unit...Psychologist: Provides psychological and neuropsychological testing when the need is indicated and is available for consultation upon request...Director of Social Services: Responsible for the oversight of all social services activities and proves general supervision to staff involved with case management and discharge planning...Therapists: Licensed counselors, behavioral, marriage, and family therapists, clinical social workers, and/or certified addictions counselors are responsible for the direct provision of counseling and crisis intervention services...Paraprofessional Psychiatric Aides: Paraprofessionals and Behavioral Health Technicians are responsible for the day-to-day unity activities, maintenance, and other (nursing) duties as assigned by the nursing staff...."

The facility's scope of practice revealed that the facility provides treatment for patients with mental health issues, serious mental illness, co-occurring disorders, and substance abuse through various departments and modalities including nursing and social services as well as counseling and psychotherapy both individually and in groups.

A review of the facility staff roster revealed that the facility employed one [social worker]. The roster revealed that the facility did not employ a Director of Social Services, nor BHPs or other licensed behavioral health staff to provide therapy, counseling, and crisis services.

A review of the [social worker's] personnel file revealed that there was no proof of orientation, education, and training on file.

Employee #21 confirmed on 10/18/2022 that the facility's [social worker] did not have a proof of proper license and education on personnel file.

Employees #15, 16, 19, 20, and 21 all confirmed in separate interviews conducted from 10/17/2022 through 10/19/2022 that the facility does not have licensed therapists or counselors to provide either group or individual counseling and therapy treatments for patients at the facility. Employees #15 and 21 further confirmed in an interview conducted on 10/19/2022 that there are no therapists to provide "process" groups as listed in the facility group schedule.

Employees #2 and 15 confirmed on 10/18/2022 that the facility does not have a director of social services, therapists, or counselors employed at the hospital.

Based on review of facility documents, personnel documents, and interview, it was determined that the facility failed to ensure a licensed professional provided clinical oversight and supervision to BHTs (behavioral health technician), BHPPs (behavioral health paraprofessional), and nursing personnel. This deficient practice poses a potential risk that the facility has a proper licensed professional to provide supervision and oversight to BHTs, BHPPs, and nursing personnel to ensure safe delivery of patient care needs are adequately provided to the specific patient population.

Findings include:

The policy titled "Clinical Supervision, Clinical Oversight and Directional Supervision" requires: "...Clinical Supervision involves direct observation of skills and services proved to members and/or family of members...Clinical Oversight involves direct interaction (non-electronic) between the Behavioral Health Professional and the staff member receiving clinical oversight and may include direct observation, communication from the treatment team and record reviews in order to verify the needs of members are met...Clinical Supervision...Behavioral health paraprofessionals shall receive a minimum of one (1) hours of direct (face-face observation) clinical supervision every two weeks. Documentation of supervision will be recorded by a person who: Is one of the following: behavioral health professional ...or behavioral health technician with a combination of full-time behavioral health work experience and education in a field related to behavioral health totaling at least six years...If a behavioral health paraprofessional provides services under the practice of marriage and family therapy, the practice of professional counseling, the practice of social work, or the practice of substance abuse counseling as defined in A.R.S. § 32-3251, that staff member is under the supervision of an individual licensed pursuant to A.R.S. Title 32, Chapter 33...Behavioral health technicians shall receive a minimum of one (1) hour of direct clinical oversight every two weeks. Documentation of clinical oversight will be recorded by a person who meets the following criteria: ...Clinical oversight shall be provided by a Behavioral Health Professional...If a behavioral health technician provides services under the practice of marriage and family therapy, the practice of professional counseling, the practice of social work, or the practice of substance abuse counseling as defined in A.R.S. § 32-3251, that staff member is under the clinical oversight of an individual licensed pursuant to A.R.S. Title 32, Chapter 33...Licensed nurses shall receive a minimum of one (1) hour of clinical oversight per month. Clinical oversight shall be provided by the director of nursing/supervisor or equally qualified designee...Licensed therapists and staff licensed under A.R.S. Title 32 who perform services described therein shall meet requirements of their professional certification or licensure. Monthly clinical oversight shall be proved by a behavioral health professional...."

The staffing roster revealed that the facility had one [social worker (BHT)] and multiple "residential techs" (combination of BHTs and BHPPs) employed at the facility.

Employee #13's last "Supervision" was dated 08/15/2022. The "supervision" was not provided by a Behavioral Health Professional (BHP) or at an interval of every two weeks.

Employee #21's last "Supervision" was dated 06/05/2021 (sic). The "supervision" was not provided by a Behavioral Health Professional (BHP) or at an interval of every two weeks.

Employee #18's last "Supervision" was dated 08/15/2022. The "supervision" was not provided by a Behavioral Health Professional (BHP) or at an interval of every two weeks.

Employees #6, 9, 17, and 20's "Supervision" documentation was not provided.

Employees #2, 15, and 16 confirmed in an interview conducted on 10/19/2022 that [BHTs and BHPPs] at the facility are not provided clinical oversight and supervision by a [BHP]. Additionally, Employee #2 and 16 confirmed that unlicensed "lead" techs, some of which are [BHPPs] provide supervision for [BHTs and BHPPs] at the facility and that clinical oversight and supervision has not been conducted every two weeks as required for [BHTs and BHPPs] or every month for nursing staff.

Based on observation, facility documents, and interviews, it was determined that the facility failed to ensure that the hospital had a director of psychiatric nursing services to oversee the management of nursing services provided by the facility. This deficient practice poses a potential risk if a facility does not have a director of psychiatric nursing services to oversee the provision of safe and effective nursing patient care to the patient population.

Findings include:

Observations during the tour of the faciltiy revealed a bulletin board posted in the hospital lobby that listed the name of the current hospital administrator and the medical provider. But the position for director of nursing stated "TBD".

The facility organizational chart that was provided for review on 10/17/2022 revealed that the director of nursing position for the hospital is vacant.

The facility staffing roster revealed that the facility does not have a director of nursing on staff.

The job description titled "Director of Nursing" revealed: "...Position Summary...The Director of Nursing is responsible for the management of ChangePoint Psychiatric Hospital's nursing department and for the direction and supervision of all nursing functions and activities. The Director of Nursing is also responsible for the quality of customer care and monitors that sufficient and competent personnel carry out the functions of nursing services. Administrative responsibilities include planning and managing nursing services, evaluation of staff, and resource allocations...Position Requisites...Required: Bachelor's Degree from an accredited Nursing school or an Associate's Degree from an accredited school...Current Arizona RN license...Four years of recent clinical experience including one (1) year of administration...."

Employees #15, 19, and 20 confirmed in an interview conducted on 10/17/2022 that the facility does not have a director of nursing services. Both employees confirmed that the prior [director of nursing services] "left a couple of months ago" and replacement has not been established by the facility. Employees #19 and 20 confirmed that they report to the [hospital administrator] who is not a nurse.

Employees #2 and 15 confirmed in an interview conducted on 10/18/2022 that the facility does not have a current director or nursing services to oversee the provision of nursing services of the facility. Employee #2 did not provide a projected hire date for the director of nursing. But stated that the facility has been without a director of nursing services for "a couple of months" and that nursing services is under the direction of the [administrator] of the facility who does not have the necessary nursing training, education, experience, and background.

Based on the review of facility documents and interviews, it was determined the facility failed to ensure a director of social services was employed by the facility to oversee the social care needs of the specific patient population. This poses a potential risk if a facility does not have a director of social services to oversee in meeting the social care needs of the specific patient population.

Findings:

The job description titled "Social Serviced Director" revealed: "...This position provides assessment and discharge services for patients, families and involved agencies. Provides coordination and communication with ChangePoint's clinical outpatient staff, medical service staff, and other community agencies and medical facilities. This position will be responsible for supervising a staff of the Social Services Department...Works in coordination with Provider, Nursing, and Social Worker...Participates in the Performance Improvement processes...Provides supervision to assigned staff...Qualifications and Experience Required: Master's Degree in Social Work or equivalent combination of education and experience...Must be certified under A.R.S. Title 32, Chapter 33 or Nationally recognized credentialing...."

The facility "Organizational Chart" provided on 10/17/2022 revealed that the "Social Services Manager" position was vacant, and open position.

Employees ##2, 15, and 21 confirmed in an interview conducted on 10/19/2022 that the facility does not have a director of social services.

Based on the review of personnel files and interviews, it was determined that the facility failed to ensure that the facility personnel had proper training, education, and experience to provide the social care needs of the patient population. This deficient practice of ensuring that a personnel has the proper education, training, and experience in the provision of social services care needs poses a potential risk of inadequate provision of appropriate social care needs specific to the patient population.

Findings include:

Employee #21's personnel file revealed that there was no facility orientation or competencies in the file.

Employee #21 confirmed in an interview conducted on 10/18/2022 that s/he had a bachelor's degree but his/her education was not in social work. Additionally, Employee #21 verified that his/her job responsibilities include developing crisis plans, biopsychosocial assessments, and treatment plans, completing suicide assessments and other assessments for substance abuse and withdrawal, acting as a liaison with families, participating in the adult recovery team, going to court for involuntary patients under Title 36, and occasionally conducting therapeutic groups. However, Employee #21 stated that due to the facility only having one [social worker] and absence of a [director of social services] therapeutic groups are often canceled.

Employees #15 and 16 confirmed in an interview conducted on 10/19/2022 that the facility does not have a social worker or director of social services that has a Master's of Social Work.