HospitalInspections.org

Based on document review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) program, collected data to monitor the effectiveness, safety and quality or specified the frequency and detail of data collection for 12 of 18 services (Alcohol/Drug services, animal therapy, biomedical engineering, biohazard waste hauler, housekeeping, laboratory services, laundry services, maintenance services, pharmacy services, psychology services, security and transcription).

Findings include:

1. Review of the Organizational Quality Improvement Plan, Last Revised 9/2017, indicated the following:
A. Objective and statistically valid performance measures are identified for monitoring and assessing processes and outcomes of care....
B. Data will be collected from internal sources (staff) and external sources (patients, referral sources, etc.).

2. Review of QAPI meeting minutes (together with attached reports) dated 1/3/18, 1/31/18, 2/28/18, 3/26/18, 4/25/18 5/30/18, 6/27/18, 7/25/18 and 8/27/18, lacked documentation of the committee having established or reviewed data for alcohol/Drug services, animal therapy, biomedical engineering, biohazard waste hauler, housekeeping, laboratory services, laundry services, maintenance services, pharmacy services, psychology services, security and transcription.

3. The following was indicated in interview:
A. On 12/18/18, between approximately 10:00 a.m. and 12:30 p.m., A7, Quality and Infection Control, indicated alcohol and drug services were included in the hospital review of therapy services. A7 verified that the hospital lacked documentation of data collected specific to those services. A7 also verified the QAPI program/Hospital did not have documentation of data to be collected with specifications for collection or data having been collected for quality review of animal therapy, biomedical engineering, biohazard waste hauler, housekeeping, laboratory services, laundry services, maintenance services, pharmacy services, psychology services, security and transcription.
B. On 12/18/18, at approximately 12:00 p.m., A2, Environment of Care Director, indicated that data collections had not been specified and data, as now understood, had not been collected for biomedical engineering, biohazard waste hauler or housekeeping.

Based on document review and interview, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program conducted performance improvement projects to the scope and complexity of the hospital's services and operations for 1 facility and failed to document the reason for conducting the quality improvement project in 2017.

Findings include:

1. Review of the Organizational Quality Improvement Plan, Last Revised 9/2017, lacked documentation of a plan for the hospital to conduct performance improvement projects.

2. The following was indicated in interview:
A. On 12/17/18, between approximately 12:45 p.m. and 3:00 p.m., A7, Quality and Infection Control, indicated that the QAPI program used FMEA (Failure Mode Effects Analysis) for "projects". A7 indicated the hospital did not have a policy on FMEA as this was a Joint Commission requirement. A7 indicated the most recent FMEA was done in 2017 on AMA (Against Medical Advice) discharges.
B. On 12/18/18, between approximately 12:00 p.m. and 1:15 p.m., A7 indicated the AMA project was started in the first quarter of 2017 and concluded in the 3rd quarter of 2017. A7 indicated that the hospital did not have a FMEA in place between 3rd quarter 2017 and present, but were currently working on implementing a project for suicide and safety risks, but that was not ready yet. A7 indicated the hospital did not have documentation of a project or FMEA prior to 2017.

3. Review of documentation for the 2017 AMA FMEA/project indicated the hospital had one document titled FMEA Summary with attached power point slides. The document and attachments lacked documentation of the reason for conducting the project/FMEA.

Based on document review and interview, medical staff (MS) failed to examine credentials for 3 of 7 MS candidates (MD4, AH2 and AH4) to ensure candidate experience prior to appointment and privileging in accordance with bylaws, failed to determine MS category in accordance with the bylaws for 1 of 1 Residents (MD4) and 2 of 3 Allied Health (AH2 and AH4) by assigning them to the category of Active Staff and failed to make recommendations to the governing body on the appointment of 2 of 4 MS members (MD1 and AH2) in the past 4 quarters.

Findings include:

1. Review of Hospital Medical Staff Bylaws, Last Revised 11/2018, indicated the following:
A. Review by the MEC (Medical Executive Committee): The MEC (or a subcommittee appointed by the MEC and comprised of MEC members) shall examine all evidence and documentation demonstrating the character, professional competence, qualification, ethical standing and health of the applicant.
B. Medical Staff shall be assigned a category of Staff membership based on the qualifications set forth below.
i. Residents and Interns, Telemedicine providers and Allied Health Professionals must be credentialed and are recognized by the Medical Staff, but shall not be considered Members of the Medical Staff.
ii. Upon initial appoint (sic) to the MS and at each time of reappointment, the Member's Staff category shall be determined.
C. The Active Staff (AS) shall consist of Members who:
i. Meet the basic requirements for Staff membership set forth in Article 3 of these Bylaws.
ii. Are regularly involved in the care of patients..."Regularly involved" means admitting a sufficient number of inpatients or outpatients...this shall mean admitting the equivalent of an average 10 inpatients each MS year.
D. Residents and Interns, or the institution with which they are affiliated, must have a separate agreement with the Hospital. The agreement shall govern the terms and conditions of the Residency and Intern program. Residents and Interns must demonstrate such clinical capabilities as the MEC shall deem appropriate. Residents and Interns are not members of the Medical Staff.
E. Allied Health Professionals. It is recognized that other healthcare professionals may provide definitive and beneficial care to the hospitalized patient and these healthcare professionals merit a position in the healthcare organization, even though they are not be (sic) Members of the Medical Staff.
i. Independent Allied Health Professionals (AHP) (e.g., Psychologists and Nurse Practitioners in those states that provide for independent practice) may be granted AHP membership and Clinical Privileges based on their documented training, experience, and current competence.
ii. Non-physician AHP, as approved by the Board, include...Nurse Practitioners with collaborative practices. The MEC upon receipt of such application shall review and investigate the qualifications of the applicant and forward its recommendations to the Board.
F. Requests for Clinical Privileges shall be evaluated on the basis of the applicant's; course work; training; treatment results; experience; character; peer recommendations; and demonstrated judgment and ability to provide, with reasonable accommodation, safe and competent care...

2. Review of credential files indicated the following:
A. On 9/10/17, MD4, medical resident, was initially appointed to the MS with clinical privileges granted.
i. MD4 was assigned to the following staff categories:
a. Active
b. Residents/Interns
c. Telemedicine
ii. MD4 was granted privileges for the following: Management of Medical Medications. Consultation for Medical Issues. Ongoing Monitoring for Medical Issues. Write Orders and Document in Progress Notes Related to Necessity. Prescribe and Monitor Buprenophine (Suboxone). Interpret Laboratory Findings. Order Radiological Services when Clinically Indicated. History and Physical. Note: Suboxone was marked through with a hand written note to the side: Removed per "corp." request, this lacked documentation of the date of or reason for removal.
iii. The credential file lacked documentation of MD4 having completed residency.
iv. The file, and hospital contracts, lacked documentation of an agreement with a Hospital to which MD 4 was affiliated.
v. The file lacked documentation of MD4's professional competence and experience.
vi. The file lacked documentation of MD4 having restrictions on privileges
B. On 5/21/18, AH2, nurse practitioner (NP), was initially appointed to the MS with clinical privileges granted.
i. AH2 was assigned to the following staff categories:
a. Active
b. Telemedicine
ii. AH2 was granted privileges for the following: Admission (Inpatient, Partial Hospitalization, Outpatient) for Substance Abuse, Psychiatric and Geriatric; Comprehensive Psychiatric Evaluation; Management of Psychotropic and Medical Medications; Write Orders and Document in Progress Notes; Ongoing Consultation and Treatment; Interpret Laboratory Findings; Order Radiological Services when Clinically Indicated; Discharge Summary; Consultation for Medical Issues; Ongoing Monitoring for Medical Issues; and History and Physical.
iii. The file lacked documentation of AH2's experience and competence to perform duties of the privileges granted.
C. On 7/23/18, AH4, nurse practitioner, was initially appointed to the MS with clinical privileges granted.
i. AH4 was assigned to the following staff categories:
a. Active
b. Telemedicine
ii. AH4 was granted privileges for the following: Admission (Inpatient, Partial Hospitalization, Outpatient) for Substance Abuse, Psychiatric and Geriatric; Comprehensive Psychiatric Evaluation; Management of Psychotropic and Medical Medications; Write Orders and Document in Progress Notes; Ongoing Consultation and Treatment; Interpret Laboratory Findings; Order Radiological Services when Clinically Indicated; Discharge; Transcription of Comprehensive Psychiatric Evaluation and Discharge Summary; Consultation for Medical Issues; Ongoing Monitoring for Medical Issues; and History and Physical.
iii. The file lacked documentation of AH4's experience and competence to perform duties of the privileges granted.

3. Review of MEC Meeting minutes dated 10/23/17, 1/29/18, 4/30/18, 7/23/18 AND 12/10/18 lacked documentation of MEC recommendation for MS appointment and/granting of privileges as follows:
A. For MD1 whose appointment letter indicated an initial appointment date of 1/4/18.
B. For AH2 whose initial appointment with privileges was indicated to have been granted on 5/21/18.

4. On 12/19/18 between approximately 10:00 a.m. and 11:30 a.m., A5, Human Resources Director, verified the following:
A. MD4 was a resident whose file indicated s/he was assigned to the category of Active Staff and was granted unrestricted privileges. A5 indicated s/he was not aware of a contract between this hospital and MD4's affiliated hospital. A5 verified the file lacked documentation of MD4's experience and/or competence.
B. AH2 was a NP whose file indicated s/he was assigned to the category of Active Staff and telemedicine and that the file lacked documentation of verification of the competence and/or experience of AH2.
C. AH4 was a NP whose file indicated s/he was assigned to the category of Active Staff and telemedicine and that the file lacked documentation of verification of the competence and/or experience of AH4.

5. On 12/19/18 between approximately 10:00 a.m. and 11:30 a.m., A7, Quality and Infection Control, verified documentation of recommendation for MS membership and privileging would be in the MEC meeting minutes and that the past 4 quarters of minutes lacked documentation of recommendation for appointment and privileging of MD1, MD2 and AH2. A7 also verified the discrepancy with bylaws in assignment to Active Staff category for MD4, AH2 and AH4.

6. On 12/19/18 between approximately 10:00 a.m. and 11:30 a.m., A1, Chief Executive Officer, verified the hospital did not have an agreement with the affiliate hospital of MD4. A1 further indicated that documentation on the appointment letter was a clerical error and that MD4 was a fully licensed physician in residency, but was not practicing at the hospital as a resident, but more as a "moonlighter". A1 verified that the hospital did not have documentation of the experience and competence of MD4 to perform duties for which s/he was granted privileges.

A Validation Survey was conducted by the Indiana State Department of Health.

Survey Date: 12/17/18 and 12/19/18

Facility Number: 012250

Brentwood Springs was found not in compliance with Requirements for Participation in Medicare, 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 Occupancies.

This one story facility was determined to be of Type II (000) construction and was fully sprinklered. The facility has a fire alarm system with hard wired smoke detectors in the corridors and spaces open to the corridors. The facility has a capacity of 48 and had a census of 45 at the time of this survey.

Based on observation and interview, the facility failed to provide a hard surface to a public way for 3 of 8 exit discharge areas (see tag K271, K353 and K354).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to provide a hard surface to a public way for 3 of 8 exit discharge areas. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on observations on 12/18/18 between 1:15 p.m. and 2:30 p.m. during a tour of the facility with the Director of Environmental Care and Corporate Director of Environmental Care, the three west exits from the Willow Unit, Cedar Unit, and the middle exit to the smoking area all exited to a courtyard. There were no sidewalks to a public way from any of the three west exits. Based on interview at the time of observations, the Director of Environmental Care said the facility has already put in place a plan for adding sidewalks from all three west exits and was able to provide an overhead diagram of the facility with locations of the sidewalks to be constructed.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request and failed to provide a complete written policy containing procedures to be followed for the protection of 45 of 45 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.6 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, there was documentation available that quarterly sprinkler inspections were performed on 01/25/18, 03/27/18, 06/11/18, and 09/14/18, plus one gauge and valve inspection in December of 2018 performed by in house staff. Monthly wet sprinkler system gauge inspection documentation for 7 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 7 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the Director of Environmental Care said the facility performs regular visual sprinkler system inspections but has not documented sprinkler system gauge and system control valve inspections on a regular basis and acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations on 12/18/18 with the Director of Environmental Care and Corporate Director of Environmental Care during a tour of the facility from 1:15 p.m. to 2:30 p.m. there were two sprinkler system pressure gauges at the sprinkler riser.

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, the facility provided fire watch documentation, however, it was incomplete. The plan failed to include the following:
a. The web link for contacting the Incident Reporting System located on the Indiana State Department of Health Gateway
b. The phone number for the local fire department
c. The phone number for the facility's insurance carrier
Based on an interview at the time of record review, the Director of Environmental Care agreed the fire watch policy lacked the previously mentioned information and said this was the only fire watch policy available.

Based on document review and interview the facility failed to ensure they followed their policy/procedure for discharge planning in 4 (N5, N10, N12 and N26) of 30 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, Discharge and Transition Planning, PolicyStat ID: 5199600, revised/reviewed 10/18 indicated: "The facility engages in ongoing transition planning at the start of services, throughout the course of treatment and at the time of discharge. This information will be facilitated by using the Discharge Planning Form...The form will be initiated at admission and indicate when and where all discharge information is documented in the chart. Information that will be documented in the chart minimally includes: Information on family sessions".

2. Review of patient N26's MR lacked documentation of completion of the Discharge Planning Form. Review of patients' N5, N10, N12 and N26's MR lacked documentation of information on family sessions.

3. On 12/18/18 at approximately 1300 hours, staff P1 (Director of Nursing) was interviewed and confirmed patient N26's MR lacked documentation of a completed Discharge Planning Form. Staff P1 confirmed N5, N10, N12 and N26's MR lacked documentation of information on family sessions. Staff P1 confirmed staff should follow policy/procedure for discharge planning.

Based on record review and interview, the facility failed to ensure that treatment goals in the master treatment plans (MTP) were stated in measurable terms that delineated specific outcome behaviors for patients for eight (8) of eight (8) sample patients (A12, A16, A18, A21, B1, B2 B6 and B8). In addition, some goals were statements of treatment compliance, rather than treatment outcomes. This failure hinders the treatment team's ability to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review

1.Patient A12 (MTP dated 12/11/18)

For problem, "increased thoughts of suicide, dep (depression]) anx (anxiety) (sic) ..." a long-term non-measurable goal was stated as "By discharge the patient will: more (sic) hopeful, less depr (depressed) and anx. (anxious) ..."

A short-term goal was stated as "Pt (Patient) will attend at least 50% of recreation therapy groups to improve use of leisure activities as coping skills." The first portion of this goal statement was treatment compliance and the last portion was non-measurable.

2.Patient A16 (MTP dated 12/11/18)

For problem, " ...confused, but also depressed and anxious," a long-term non-measurable goal was stated as "By discharge the patient will: feel for hopeful, more stable both mentally and physically."

A short-term goal was stated as "Pt (Patient) will attend at least 50% of recreation therapy groups to improve coping skills for anxiety." The first portion of this goal statement was treatment compliance and the last portion was non-measurable.

3.Patient A18 (MTP dated 12/9/18)

A. For problem, " ...reports thoughts of hopelessness when it came to [his/her] detox (detoxification) and vague SI (suicidal ideation)." A long-term non-measurable goal was stated as "By discharge the patient will: no longer have thoughts to harm [him/herself]. Pt's (Patient's) medication will be managed. [S/he] will have aftercare developed."

A short-term non-measurable goal was stated as "Pt (Patient) will no longer have thoughts to harm [him/herself] due to feelings as (sic) though [his/her] medications are managed."

b. For problem, " ...struggling to detox (detoxify) from methadone and soboxone,"
a long-term non-measurable goal was stated as "By discharge the patient will: have detoxed with medication management."

A short-term non-measurable goal was stated as "Pt (Patient) will determine [his/her] aftercare to maintain recovery."

4. Patient A21 (MTP dated 12/10/18)

A. For problem, " ...having thoughts to end [his/her] life by cutting an artery,"
a long-term non-measurable goal was stated as "By discharge the patient will: no longer have thoughts to harm [him/herself]."

A short-term non-measurable goal was stated as "Pt (Patient]) will have developed 5 coping skills to use when feeling increased (sic) depression and suicidal thoughts."

B. For problem, " ...reports using meth (methamphetamine) monthly and marijuana daily," a long-term non-measurable goal was stated as "By discharge the patient will: have developed coping skills to reduce cravings and exchange negative behaviors for positive."

A short-term non-measurable goal was stated as "Pt (Patient]) will have developed 3 coping skills to use instead of using a substance."

5.Patient B1 (MTP dated 12/11/18)

a. For problem, "[Patient] relapse (sic) after 6 months sober resulting in disruption across life speres (sic)," there was no long-term goal identified.

A non-measurable treatment compliance statement was stated as a patient goal: "Pt (Patient) will participate in 5 to 7 rec (recreation) therapy group (sic) weekly at 80% or better to improve coping and leisure skills."

b. For problem, "Deepening depression resulting in H/I (homicide ideation) + (and) threats to act out in anger, issue of PTSD (Post Traumatic Stress Disorder)," there was no long-term goal identified.

A non-measurable short-term goal was "Pt (Patient) will address anger management-declines to accept goal."

6. Patient B2 (MTP dated 12/12/18)

a. For problem, "Patient is here due to [his/her] drinking turning into excessive drinking over past two years. [S/he] is experiencing cravings and obsessive thoughts," a long-term non-measurable goal was stated as "By discharge the patient will: have decreased cravings and decreased obsessive thoughts."

A non-measurable treatment compliance statement was identified as a patient goal: "Pt (Patient) will participate 5 to 7 time (sic) at 80% in rec (recreation) therapy groups weekly to improve coping and leisure skills."

b. For problem, "Patient experiences extreme residual reactions and emotions from a deployment in 2015 ..." a non-measurable long-term goal is stated as "By discharge the patient will: have decreased shortness of breath, decreased night terrors, decreased sleep paralysis, decreased thoughts of not wanting to wake up, deceased (illegible)."

7. Patient B6 (MTP dated 11/17/18)

For problem, " ...psychosis presenting as delusions as well as mood lability,"
a long-term non-measurable goal was stated as "By discharge the patient will: have complied with medication management with reduce (sic) mood lability and psychosis symptoms."

A non-measurable treatment compliance statement was identified as a short -term patient goal: "Pt (Patient) will comply with provider for medication management by time of discharge."

A non-measurable short-term goal was "Pt (Patient) will learn 2 new ways to relax."

8. Patient B8 (MTP dated 12/8/18)

a. For problem, "Pt (Patient) reports having feelings of someone out to get [him/her] and ...reports having thoughts and plan to end [his/her] life," a non-measurable long-term goal was stated as "By discharge the patient will: no longer have thoughts to harm [him/herself]." A long-term goal stated as treatment compliance was "Pt (Patient) will have complied with medication management to reduce or eliminate hallucinations and paranoia."

A short-term goal stated as treatment compliance was "Pt (Patient) will comply with medication management to reduce paranoia and hallucinations."

b. For problem, "Reports using Xanax and taking [his/her] prescription of Suboxone. Pt (Patient) has history of poly-substance use," a non-measurable short-term goal was "Pt (Patient) will develop 5 ways to reduce cravings."

B. Interview

During interview with review of treatment plans on 12/18/18 at 9:35 a.m. the Director of Nursing and the Director of Social Work verified the above findings.

Based on record review and interview, the facility failed to adequately develop and document individualized physician and nursing treatment interventions on the Master Treatment Plan (MTP) with specific purpose and focus based on the needs of eight (8) of eight (8) active sample patients (A12, A16, A18, A21, B1, B2, B6 and B8). These interventions presented with the identical format for each patient with few deviations. This deficiency results in a failure to provide a basis for accurate implementation to evaluate treatment provided and to plan revisions based on individual patient needs and findings.

Findings include:

A. Record Review

1. Patient A12 (MTP dated 12/11/18) had the following problem statement: "Increased thoughts of suicide, depression and anxiety. Patient report [sic] feeling hopeless." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate patient re: depression, course of illness, and assess medication effects including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] 12 hours for signs of depression, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

2. Patient A16 (MTP dated 12/11/18) had the following problem statement: "Patient admits to feeling confused but also depressed and anxious." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate re: course of treatment, course of illness, and assess medication effects, including side effects."

--Nursing Intervention: "Nursing will assess patient q [every] shift for SI [suicidal ideation], anxiety, depression, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

3. Patient A18 (MTP dated 12/9/18) had the following problem statement: "Patient reports having thoughts of hopelessness when it came to [his/her] detox and vague SI [suicidal ideation]." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate patient re: course of treatment, course of illness and assess medication effects, including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] shift for anxiety, depression, SI [suicidal ideation], behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

4. Patient A21 (MTP dated 12/10/18) had the following problem statement: "Pt [patient] reports having thoughts to end [his/her] life by cutting an artery." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate patient re: depression, course of illness, and assess medication effects including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] 12 hours for signs of SI [suicidal ideation] and depression, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

5. Patient B1 (MTP dated 12/11/18) had the following problem statement: "Recent relapse after 6 month sober resulting in disruption across life speres [sic]." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet patient daily to educate patient re: ETOH [alcohol] w/d [withdrawal], course of illness, and assess medication effects including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] 6 hours for signs of ETOH [alcohol] detox, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

6. Patient B2 (MTP dated 12/12/18) had the following problem statement: "Patient is here due to [his/her] drinking turning into excessive drinking over the past two years." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate patient re: addiction, course of illness, and assess medication effects, including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] 12 hours for withdraw [sic], behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

7. Patient B6 (MTP dated 11/17/18) had the following problem statement: "Patient was assessed with psychosis presenting as delusions as well as mood lability." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient Q [every] day to educate patient re: psychosis, course of illness, and assess medication effects, including side effects."

--Nursing Intervention: "Nursing will assess patient Q [every] shift for SI [suicidal ideation], psychosis, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

8. Patient B8 (MTP dated 12/8/18) had the following problem statement: "Patient reports having feelings of someone is out to get [her/him] and that [s/ he] was 'hearing shit'. Patient reports having thoughts and plan to end [his/her] life." Interventions were as follows:

--Physician Intervention: "Medical Provider will meet with patient daily to educate patient re: course of treatment, course of illness, and assess medication effects, including side effects."

--Nursing Intervention: "Nursing will meet with patient each shift for dep [depression], anx [anxiety], suicidality, behavior, and effectiveness of medication."

These interventions were generic, routine discipline tasks. They were not individualized to address the patient's needs.

9. The facility policy, #4284708, titled "Treatment Planning-Philosophy and Purpose" and dated 2/18 stated, "Interventions are: Sufficiently specific to evaluate patient's progress. Expressed in behavioral terms that specify measurable indices of progress."

This policy was not followed in the development of treatment plans.

B. Interviews

1. On 12/18/18 at 12:05 p.m., the Medical Director agreed that the treatment plan interventions were not individualized.

2. On 12/18/18 at 9:30 a.m., the Director of Nursing agreed that nursing interventions were not individualized; stating, "That's not our strong suit."

Based on observations, interview and record review, it was determined that monitoring and evaluation by the Medical Director failed to include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. Specifically the Medical Director failed to:

A. Ensure that treatment goals in the master treatment plans (MTP) were stated in measurable terms that delineated specific outcome behaviors for patients for eight (8) of eight (8) sample patients (A12, A16, A18, A21, B1, B2 B6 and B8). In addition, some goals were statements of treatment compliance, rather than treatment outcomes. (Refer to B121)

B. Ensure the development and documentation of individualized physician interventions on the Master Treatment Plan (MTP) with specific purpose and focus based on the needs of eight (8) of eight (8) active sample patients (A12, A16, A18, A21, B1, B2, B6 and B8). (Refer to B122)

C. Ensure sufficient review of deaths of patients (I1 and I2) who had been recently discharged from the facility. This failure hindered corrective actions based on review findings to ensure quality treatment of patients.

Findings include:

1. A review of the documentation for Patients I1 and I2 reveal that the facility had not conducted a formal review of the deaths of these patients after their deaths.

2. The Chief Executive Officer stated on 12/18/18 at 2:10 p.m. that the facility had not completed a root cause analysis regarding this death. At this time, the Director of Quality Management concurred that there was no root cause analysis and that the facility had no policy regarding a formal review of a death that was not characterized as a suicide.

Based on record review and interview, the Director of Nursing failed to ensure that nursing interventions on the Master Treatment Plan were individualized for eight (8) of eight (8) active sample patients (A12, A16, A18, A21, B1, B2, B6 and B8). These interventions presented with the identical format for each patient with few deviations. This deficiency results in a failure to provide a basis for accurate implementation, to evaluate treatment provided and to plan revisions based on individual patient needs and findings. (Refer to B122)