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Based on document review and interview, it was determined that for 1 (Pt. #25) of 2 clinical records reviewed for allegation of sexual assault, the Hospital failed to ensure that staff followed the policy in handling of a sexual assault victim. This has the potential to affect all current and future patients with allegation of sexual assault at risk for serious harm. As a result, the Condition of Participation for Patient Rights 42 CFR 482.13, was not met.

Finding include:

1. The Hospital failed to follow their policy in handling of a sexual assault victim (Pt #25), thus delaying the medical treatment. See deficiency cited at A-145 A.

The immediate jeopardy (IJ) began on 1/13/19 when the Hospital was made aware by Pt. #25 that she had been sexually assaulted by a staff on 1/12/19. Pt. #25 was not offered a post sexual assault medical evaluation until 1/15/19 (2 days after Pt. #25 had disclosed to the Hospital staff of the event on 1/12/19).

The IJ was identified and announced on 6/28/19 at 3:25 PM during a meeting with the Chief Executive Officer (E #18), Performance Improvement and Risk Management Director (E #1) and the Divisional Clinical Service Director (E #16). The IJ was removed by the survey exit date on 6/28/19 at 4:30 PM.

On 6/28/19 the Facility presented their immediate jeopardy removal plan that included:

- A Hospital policy titled "Sexual Aggression and Sexual Victimization: Prevention Response and Notification plan" (reviewed 6/27/19) was revised and included the following revisions "...5. Response to sexual allegation...Notify [Physician/Advance Practice Nurse] and nursing supervisor of the incident; Offer patient(s) transport to the [Emergency Room] for rape/trauma evaluation for cases involving any sexual allegation of touching genital/anal area, oral, anal vagina penetration or for patient that is unable to provide a clear description of sexual misconduct; If patient refused [Emergency Room] [Registered Nurse] will document refusal in medical record and contact medical physician to exam patient [as soon as possible] but no longer than 24 hours of notification...6. Notification: ...Charge Nurse will notify the Nursing Supervisor and [Physician/Advance Practice Nurse] immediately...[Patient] to [Emergency Room [for] evaluation/rape kit; If patient refuses to go to the [Emergency Room], the internist will be informed for providing orders as indicated..."

- On 06/27/19 the Hospital initiated education about the revised policy on "Sexual Aggression and Sexual Victimization: Prevention Response and Notification Plan" (rev. 6/27/19) to the following departments: Nursing, Social Services, Emergency Services, Psychology, Medical Staff, Expressive Therapy and Substance Abuse. On 6/28/19 at approximately 9:00 AM, the Hospital had trained approximately 33% of their staff on this revised policy.

- An Audit tool was created to include the required documentation in a patient's clinical record for sexual allegation and will be monitored by the [Chief Clinical Officer] and the Performance Improvement and Risk Director.

On 6/28/19 at approximately 9:00 AM, the Chief Executive Officer (E #18) was interviewed. During the interview, E #18 stated "Allegations of sexual abuse are not taken lightly. In an effort to ensure that this does not occur in the future we have made changes to our policy. Education is being provided to staff on what is expected when an allegation of sexual assault occurs."

2. The Hospital failed to ensure that the State Agency and the police were notified regarding the allegation of sexual assault of a staff to patient [Pt. #25] per Hospital's policy. See deficiency cited at A-145 B.

A. Based on document review and interview it was determined that for 1 (Pt. #25) of 2 clinical records reviewed for sexual assault allegation, the Hospital failed to ensure that the staff followed the policy in handling of a sexual assault victim [Pt. #25] which resulted in delayed medical evaluation and treatment of the patient.

Findings include:

1. On 6/27/19, the Hospital's policy titled "Aggressive Sexual Acting Out/Sexual contact between patients" (revised 4/2018) was reviewed and included "Sexual Allegations-Patient reports/alleges ...Sexual Misconduct- ...including ...fondling/touching another (excludes penetration) directly or through clothing another person's genitals, breast. 5. Response: Upon discovery of an allegation of sexual behavior between staff/patient ...Prepare patient for transport to ER for rape/trauma evaluation for cases involving non-consent, allegation of force, assault/rape. 6. Notification: Charge nurse obtains orders for: Evaluation/ER visit/rape kit, STD (Sexually Transmitted Disease)/HIV (Human Immunovirus), testing for all allegation of... oral sex..."

2. On 6/27/19 at approximately 11:30 AM, the clinical record of Pt. #25 was reviewed. Pt. #25 was a 15 year old female admitted on 12/24/18 with a diagnosis of major depressive disorder. The clinical record included:

- A "Nurses Notes" dated 1/13/19 at 3:03 PM included " ...Alert and Oriented x 4 [date time person and location] ...Pt [Pt. #25] noted in her room repeatedly asking if the requested female staff is coming to talk to her, the staff was informed and came to [speak] to the patient. Staff referred the [Pt. #25] to the nurse, [Pt. #25] verbalized that she was touched inappropriately repeatedly by the particular male staff on yesterday evening (1/12/19) and she [Pt. #25] was traumatized. Pt [Pt. #25] provided in depth details, stating that the staff repeatedly walked in to her room, kissed her, touched her private areas and asked for sexual acts in return. Patient [was] noticed very anxious ...nursing supervisor, risk management, attending psychiatrist and social worker notified ..."

- A "Medical Consult" dated 1/14/19 included "Chief Complaint: Alleged that someone had fondled her and touched her genital area. Please assess ..."

- The [Medical] Assessment dated 1/15/19 at 12:56 PM, by the Hospitalist (MD #1) included "[Pt. #25] reports being touched on her breast and genitals. Denied penetration. Skin exam normal. No brusing noted. Denies the need to be examined further. Plan/Recommendations: Treatment team aware."

3. On 6/27/19 at approximately 3:55 PM, the Occurrence Report dated 1/13/19 was reviewed. The report included that, on 1/12/19 at 11:00 PM, that [Pt. #25] alleged to have been sexually assaulted by staff. The Physician, Director of Nursing and family had been notified.

4. On 6/27/19 at approximately 12:00 PM, the Performance Improvement and Risk Management Director (E #1) presented a document with timeline of events for Pt. #25's incident. The document was reviewed and indicated that on 1/13/19, Pt. #25 reported that during the PM [evening] shift on 1/12/19 between 10:00 - 11:00 PM, a MHS [Mental Health Specialist] was sexually inappropriate with the patient [Pt. #25]. During the Hospital's internal investigation, two patients (Pt. #31 and Pt. #32) who had witnessed the incident provided statements that Mental Health Specialist (E #17) was sexually inapproriate toward Pt. #25. The Hospital also reviewed video surveillance which supports that E #17 spent an unusual amount of time in the patient ' s (Pt. #25) room.

5. On 6/27/19 at approximately 4:00 PM, the Director of Nursing (E #4) was interviewed. During the interview, E #4 stated, "Patient ( Pt. #25) allegation of sexual assault had occured on 1/12/19. When I came in on Monday [1/14/19], I noticed that she [Pt. #25] had not received a medical evaluation and I submitted a request for medical consultation at that time." E #4 stated that patient [Pt. #25] alleged to have been touched by E #17. E #4 stated that there was no true [sexual] assault or attack because E #17 had not penetrated [sexual intercourse] in to Pt. #25.

6. On 6/27/19 at approximately 4:15 PM, the Clinical Service Director (E #16) was interviewed and stated that any patient that alleged a sexual assault should be sent to the Emergency Room (ER) [for medical evaluation post sexual assault]. [Pt. #25] incident alleged to have occurred in a room, [Pt. #25] should have been sent to the ER.

7. On 6/28/19 at approximately 9:20 AM, the Hospitalist (MD #1) was interviewed. MD #1 stated "Depending on the time of day the consult request is made, I may see the patient that same day or the following day. The medical consult was requested on 1/14/19. I saw and evaluated [Pt. #25] on 1/15/19. If there is any possibility of any penetration [sexual intercourse], we do immediate send out [laboratory testing] for evaluation of HIV (Human Immunovirus) STD (Sexually Transmitted Disease), if it is within 48 hour window a rape kit is done. For an allegation of sexual assault, the patient should be seen immediately. I do not know why the consult was not made out until [1/14/19]. If a patient says that there is actual oral sex or exchange of fluids, we do immediate send out."





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B. Based on document review and interview, it was determined that for 1 (Pt. #25) of 2 patients reviewed for sexual assault, the Hospital failed to ensure that the State Agency and the police were notified timely regarding the allegation of sexual assault from a staff to Pt. #25 per Hospital policy.

Findings include:

1. On 06/27/19 at approximately 10:30 AM, the Hospital policy titled, "Aggressive Sexual Acting Out/Sexual Contact between Patients" dated 04/2019 was reviewed. The policy included, "5. Response: Upon discovery of an allegation of sexual behavior between staff/patient ...6. Notification: Risk Manager/Designee: Notify the police in all sexual assault, intercourse cases that involve a minor; and if either of the patients request to file a police report. Notify State Agencies and call..."

2. On 6/27/19 at approximately 11:30 AM, the clinical record of Pt. #25 was reviewed. Pt. #25 was a 15 year old female admitted on 12/24/18 with a diagnosis of major depressive disorder. The clinical record included a "Nurses Notes" dated 1/13/19 at 3:03 PM " ...Staff referred the [Pt. #25] to the nurse, patient verbalized that she was touched inappropriately...provided in depth details, stating that the staff repeatedly walked in to her room, kissed her, touched her private areas and asked for sexual acts in return. Pt. #25's clinical record lacked documentation that State Agency and police were notified of the incident.

On 6/27/19 at approximately 3:55 PM, the Occurrence Report dated 1/13/19 was reviewed and included, "On 1/12/19 at 11:00 PM, [Pt. #25] alleged to have been sexually assaulted by a staff. On the Occurence Report, the section if "Law Enforcement had been notified" was left blank."

3. On 06/28/19 at approximately 11:00 AM, the Director of Risk Management (E #1) was interviewed. E #1 stated, "We notified the State Agency. I asked one of my staff to notify IDPH (Illinois Department of Public Health). But, I am not sure if he has any paper work related to notifying the State Agency. We notified the police. But, I do not have any documentation related to the police notification when it occurred."

4. After several requests, the Hospital failed to provide documentation regarding notification to State Agency and police department.

Based on document review and interview, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Hospital's Rules and Regulations of the Medical Staff (revised ) was reviewed on 6/27/19 and included, "...Delinquent Medical Records...All portions of the medical record must be completed within thirty (30) days of discharge..."

2. On 6/27/19, the Supervisor of Medical Records (E #11) presented the surveyor with a letter of attestation which included, "...There are a total of sixteen (16) delinquent records of 6/27/19."

3. On 6/27/19 at approximately 10:30 AM, an interview was conducted with E #11. E #11 stated that, the physicians must sign and complete medical records within 30 days of discharge.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on June 25 - 26, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on June 25 - 26, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that identified long and short-term goals stated in observable, measurable patient behaviors to be achieved for 13 of 13 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). The facility also failed to ensure that goals were consistently written in language understandable to patients and free of psychiatric jargon. Due to the lack of individualized symptoms, specific descriptors, and observable behaviors on the MTPs, it would be difficult to assess the effectiveness of treatment and to implement possible changes.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (date of the plan in parentheses): A1 (4/29/19); A2 (6/6/19); A3 (6/3/19); A4 (6/19/19); A5 (6/18/19), A6 (4/30/19; last updated 6/25/19), A7 (6/14/19), A8 (4/28/19), A9 (5/3/19), A10 (5/29/19), A11 (6/21/19), A12 (12/21/18), and A13 (6/7/19). This review revealed the following deficient long-term (LTG) and short-term goals (STG).

1. Patient A1's MTP included the following goals for the problem of, "Psychosis with Fixed Delusions ... Evidenced by: delusions, patient believes that [s/he] is a federal investigator ...": LTG - "[Patient will demonstrate/report reduction of psychosis symptoms (distractibility, disorganized thoughts, delusional thoughts, paranoia, etc.)." STGs - "[Patient will identify 1-2 strategies to implement to manage symptoms of psychosis." "[Patient will comply with medication and agree to AOT [Assisted Outpatient Treatment] services 2 days prior to [his/her] discharge." These goal statements were not stated in measurable, observable, and behavioral terms. In addition, the STG related to complying with medications was a staff expectation or treatment compliance issue, not a goal related to what the patient would be doing or saying to show understanding of psychiatric symptoms and needs for medications.

2. Patient A2's MTP included the following goals for the problem of, "Psychosis - BEH [Behavior]- Evidenced by: ... an increase in psychosis- patient appears catatonic and is demonstrating word salad ...": LTG - "[Patient will demonstrate a reduction in psychotic symptoms including paranoia, catatonia, disorganized thought process within 48 hours to discharge." STGs - "[Patient will identify 1-2 strategies to implement to manage symptoms of psychosis." "[Patient will be able to attend two groups per day without being focused on contamination." These goal statements were not stated in measurable, observable, and behavioral terms. In addition, the STG related to attending groups was a staff expectation or treatment compliance issue, not a goal related to what the patient would be doing or saying to show improvement in presenting psychiatric symptoms.

3. Patient A3's MTP included the following goals for the problem of, "Psychosis with Fixed Delusions- BEH- Evidenced by: [Patient] was admitted for reported psychotic features (e.g. believes people are spreading rumors about [him/her] and want to kill [him/her], believes that [s/he] 'exists to spread the truth' preoccupied with 'spiritcookers' and Hinduism ...": LTG - "[Patient] will utilize positive coping skills to ensure safety to self and others and will not respond to command auditory hallucinations to harm [himself/herself] or others for 48 prior to discharge." STGs - "[Patient] will report a reduction to internal stimuli and will demonstrate a reduction in talking to self within 3 days." "[Patient] will verbally acknowledge fixed delusional beliefs are unreal within 48 hours to discharge." These goal statements were not stated in measurable, observable, and behavioral terms. In addition, there was no STG regarding what the patient was to do when experiencing the command hallucinations. The STG related to aftercare was not directly related to the LTG and failed to identify small steps to achieve the identified long-term goal. There was no way to determine whether the patient would share information regarding a reduction in internal stimuli, thus not a measurable goal.

4. Patient A4's MTP included the following goals for the problem of, "Psychosis - BEH- Evidenced by: [Patient] is observed to be responding to internal stimuli ... is observed to be talking to [himself/herself] ...": LTG - "[Patient] will not demonstrate reaction to internal stimuli for at least 2 days prior to discharge." STGs - "[Patient] will report a reduction to internal stimuli and will demonstrate a reduction in talking to self within 3 days." "[Patient] will verbalize at least 2 benefits of compliance with aftercare." These goal statements were not stated in measurable, observable, and behavioral terms. In addition, the STG related to aftercare was not directly related to the LTG and failed to identify small steps to achieve the identified long-term goal. There was no way identified to determine whether the patient would share information regarding a reduction in internal stimuli, thus not a measurable goal.

5. Patient A5's MTP included the following goals for the problem of, "Psychosis with Aggression - BEH- Evidenced by: [Patient] was admitted with HI [homicidal ideations] toward person that sold [him/her] marijuana ... presents with bizarre behavior ... is aggressive with others.": LTG - "By the time of discharge, [Patient] will eliminate acute reactive psychotic symptoms and return to previous level of functioning." STGs - "[Patient] will engage in reality- based conversations/activities at twice per day." "[Patient] will refrain from assaultive or aggressive behavior for at least 4 shifts prior to discharge." "[Patient] will identify at least 1 early warning sign of relapse prior to discharge." These goal statements were not stated in measurable, observable, and behavioral terms. In the absence of descriptive information regarding the patient's behavior, it would be difficult for staff to know what to observe or how to determine progress.

6. Patient A6's MTP included the following goals for the problem of, "Risk of Harm to Others/Aggression with Impulsivity - BEH- Evidenced by: [Patient] threaten to burn down home and is verbally aggressive towards foster parent.": LTG - "[Patient] will refrain from threatening or assaultive bx [behavior] for at least 48 hours prior to discharge." STGs - "[Patient] will verbalize anger through controlled, respectful verbalization and healthy physical outlets." "[Patient] will demonstrate a decrease in violence by experiencing a reduction in the following trauma-related symptoms for two consecutive days: avoidance of internal and external reminders, social and emotional detachment, hopelessness, irritability, and hypervigilance." These goal statements were not stated in measurable, observable, and behavioral terms. The goal statements did not include descriptive information regarding the patient's behavior that would be easily understood by the patient. Therefore, it would be difficult for the patient to know what to do to achieve the goal and also difficult for staff to know what to observe or how to determine progress.

7. Patient A6's MTP included the following goals for the problem of, "Harm to Self - BEH- Evidenced by: [Patient] was admitted to [Hospital] due to suicide risk attempt ... by setting the house on fire and reporting that [s/he] will do anything [s/he] can to harm [himself/herself]." LTG - "[Patient] will refrain from suicide attempts or statements for at least 3 days prior to discharge." STGs - "[Patient] will not attempt to kill self or make suicidal statements for 3 consecutive days." "[Patient] will demonstrate a decrease in suicidal ideation by experiencing a reduction in the following trauma-related symptoms for two consecutive days: intrusive thoughts, flashback, psychological and physiological distress when exposed to trauma cues, avoidance of internal and external reminders, social and emotional detachment, hopelessness, irritability, and hypervigilance." These goal statements were not stated in measurable, observable, and behavioral terms. Also, no goal statement reflected positive actions the patient would take to show to manage his/her symptoms. The goal statements contained psychiatric jargon that would not be easily understood by the patient. Therefore, it would be difficult for the patient to know what to do to achieve the goal and also difficult for staff to know what to observe or how to determine the patient's progress.

8. Patient A8's MTP included the following goals for the problem of, "Risk for Violence to Others/Threatening and Assaultive Behavior - BEH- Evidenced by: ... [Patient] pushed [his/her] aunt during an argument and threatened to kill [his/her] family. Patient denies pushing aunt and reports in fact [she] threatened [him/her]." LTG - "[Patient] will demonstrate reduction in aggression within 48 hours of discharge." STGs - "[Patient] will demonstrate reduction in aggression (physical fights, verbal threats) within one week." "[Patient] will demonstrate a decrease in violence by experiencing the following trauma-related symptoms for two consecutive days: Flashbacks, avoidance of internal and external reminders, anhedonia, social and emotional detachment, hopelessness, and hypervigilance." These goal statements were not stated in measurable, observable, and behavioral terms. Also, no goal statement reflected positive actions the patient would take to manage his/her symptoms. The goal statements contained psychiatric jargon that would not be easily understood by the patient. Therefore, it would be difficult for the patient to know what to do to achieve the goal and also difficult for staff to know what to observe or how to determine progress.

9. Patient A9's MTP included the following goals for the problem of, "Harm to Self - BEH- Evidenced by: ... Patient reports SI thoughts with a plan to harm [himself/herself] by jumping on railroad tracks." LTG - "[Patient] will not endorse suicide ideation for a least 48 hours prior to discharge." STGs - "[Patient] will demonstrate reduction in depressive symptoms within 3 consecutive shifts." "[Patient] will be able to identify triggers, coping skills, and healthy outlets." These goal statements were not stated in measurable, observable, and behavioral terms. Since the goal statements did not include descriptive information regarding the patient's behavior related to depressive symptoms and coping skills, it would be difficult for staff to know what to observe or how to determine the patient's progress.

10. Patient A10's MTP included the following goals for the problem of, "Risk of Harm to Others/Aggression with Impulsivity - BEH- Evidenced by: [Patient] was aggressive before admission by throwing a dog against the wall and breaking both of its legs. Patient has a history of aggression and ADHD medication as well." LTG - "[Patient] will demonstrate reduction in aggressive behavior and impulsivity within 48 hours of discharge." STGs - "[Patient] will demonstrate improvement in aggressive behaviors within one week." This goal statement was not stated in measurable, observable, and behavioral terms. The goal statements did not include descriptive information regarding what the patient would be doing or saying to show improvement in aggressive behaviors. Therefore, it would be difficult for staff to know what to observe or how to determine the patient's progress.

11. Patient A11's MTP included the following goals for the problem of, "Risk for Violence to Others/Threatening and Assaultive Behavior - BEH- Evidenced by: [Patient] was admitted due to reported aggression towards [his/her] grandmother (e.g. tried to push grandmother down the stairs, made verbal threats and grabbed a knife threatening [his/her] grandmother ...)" LTG - "[Patient] will utilize positive coping skills to ensure safety to others for 48 hours prior to discharge." STGs - "[Patient] will not be physically aggressive or provoking for 48 hours prior to discharge." "[Patient] will verbally identify two conflict resolution techniques to increase appropriate communication during anger episodes with [his/her] grandmother." These goal statements were not stated in measurable, observable, and behavioral terms. The goal statements did not include descriptive information regarding "coping skills," and "conflict resolution techniques." Thus, it would difficult for staff to know what to observe or how to determine the patient's progress. The goal statements also contained psychiatric jargon that would not be easily understood by the patient. Given this patient's identified level of cognitive functioning, it would be difficult for the patient to know what to do to achieve the goal.

12. Patient A12's MTP included the following goals for the problem of, "Harm to Self - BEH- Evidenced by: [Patient] endorsed suicidal ideation with plan to hang [himself/herself] two weeks ago. [Patient's] friend [Name] reported patient wrote suicide note. [Patient] report history of one prior suicide attempt ... via drinking draino." LTG - "[Patient] will be free from suicidal ideation for at least 3 days prior to discharge." STGs - "[Patient] will verbalize 1-2 feelings of sadness and hurt related to family conflicts." "[Patient] will be free from PRN/STAT medication for a total of 30 days prior to discharge." [Patient] will not endorse suicidal plan to hang self for at least 48 hours prior to discharge." These goal statements were not stated in measurable, observable, and behavioral terms. Also, no goal statement reflected positive actions the patient would take to show to manage his/her symptoms regarding suicide and family conflict. The goal statement regarding PRN medication was a staff expectation or a treatment compliance issue, not a patient outcome reflecting what the patient would be doing or saying to show understanding of the need for medications.

13. Patient A13's MTP included the following goals for the problem of, "Psychosis - BEH- Evidenced by: [Patient] was admitted due to psychosis - disorganized speech, bizarre statements, and responding to internal stimuli." LTG - "[Patient] will not display disorganized thoughts/speech during groups and individual sessions for 3 days prior to discharge." "[Patient] will state 2 benefits of compliance with medication and aftercare and 1 negative consequence of noncompliance prior to discharge." These goal statements were not stated in measurable, observable, and behavioral terms. The goal statements did not include descriptive information regarding the content of internal stimuli or the impact on the patient. Thus, it would difficult for staff to know what to observe or how to determine progress. Also, no goal statement reflected positive actions the patient would take to manage his/her symptoms associated with psychosis. The goal statement regarding non-compliance was not directly related to the LTG and failed to identify small steps to achieve the identified long-term goal.

B. Interviews

1. During an interview on 6/27/19 at approximately 9:30 a.m., the Director of Nursing did not dispute the findings that goal statements were not measurable or stated in behavioral terms.

2. In an interview on 6/27/19 at 10:25 a.m., the Director of Social Work agreed that the long and short-term goals were not individualized and not consistently related to the identified problem statements.

3. In an interview on 6/27/19 at 10:40 a.m., the Director of Psychology did not dispute the findings that goal statements contained psychological jargon that would not be understood by patients. She also did not dispute the findings that goal statements were not individualized or written in behavioral terms.

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

I. Provide 12 of 13 active sample patients (A1, A2, A3, A4, A5, A7, A8, A9, A10, A11, A12, and A13) with Master Treatment Plans (MTPs), which included individualized active interventions assigned to recreational therapists, social workers, and psychologists that stated specific treatment modalities with a specific focus or purpose based on each patient's identified problems. This deficiency results in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent or effective treatment.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following patients were reviewed (date of each plan in parenthesis): A1 (4/29/19); A2 (6/6/19); A3 (6/3/19); A4 (6/19/19); A5 (6/18/19), A6 (4/30/19; last updated 6/25/19), A7 (6/14/19), A8 (4/26/19), A9 (5/3/19), A10 (5/28/19), A11 (6/21/19), A12 (12/21/18), and A13 (6/7/19). This review revealed the following deficient long-term goals (LTG) and short-term goals (STG).

1. Recreational Therapists:

Five active sample patients had the following same or similarly worded interventions assigned to recreational therapy staff (A1, A2, A3, A4, and A13): "Encourage pt. [patient] to attend groups with eye contact during the following activities: Social Development, group games, crafts and individual leisure activities, group games, keep it up, Karaoke sing along, leisure education, and viewing a relaxing picture." This intervention was not individualized and failed to identify a focus or purpose of the intervention based on the unique presenting symptoms of each patient.

2. Social Workers:

Four active sample patients (A2, A3, A4, and A13) all had the following intervention assigned to social work staff despite patients having different presenting psychiatric symptoms: "Help pt [patient] identify thought patterns not based in reality and discuss events and people." This identically worded intervention was non-specific and not individualized to the particular targeted psychiatric symptom(s) that would be the focus of active treatment for each patient based on their presenting clinical problems.

3. Psychologists:

Thirteen active sample patients A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13 had the following identical or similarly worded intervention assigned to the psychologist: "Teach patient skills of affect recognition and regulation skills [sic], mindfulness, cognitive restructuring, and behavioral activation techniques and encourage practice of them in group and milieu." This intervention statement was non-specific, not individualized, and failed to include the focus or purpose of treatment based on each patient's presenting psychiatric symptoms.

B. Interviews

1. In an interview on 6/27/19 at approximately 9:30 a.m., the Director of Nursing acknowledged that the nursing interventions in the EMR were generic and routine functions of the registered nurses.

2. In an interview on 6/27/19 at 9:25 a.m., the Director of Social Worker agreed that the social work interventions were identical and thus not individualized.

3. In an interview on 6/27/19 at 10:30 a.m., the Director of Psychology did not dispute the findings that psychological interventions did not include a focus of treatment based on each patient's presenting symptoms. She noted, "It difficult to individualize group interventions."

II. Identify Master Treatment Plans (MTPs) that identified interventions that were specific to the patient's problems for thirteen (13) of thirteen (13) active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). The Master Treatment Plan contained predetermined interventions that were in the Electronic Medical Record (EMR). The medication interventions were not individualized and contained the same or similarly worded interventions for both psychiatrists and registered nurses. The interventions were routine generic functions of these disciplines rather than active treatment interventions for the identified problems listed in the treatment plan. There were no other treatment interventions for the identified problems on the treatment plan by the psychiatrist and registered nurse. The facility failed to identify treatment interventions that provided a focus that addressed each patient's individual needs and results in failure to guide treatment staff to achieve measurable, behavioral outcomes.

A. Record Review

1. Patient A1's MTP, dated 4/29/19, included the following deficient interventions for the psychiatric problem: "Psychosis with Fixed Delusions- Beh[Behavior] - Evidenced by:[Patient Name] presents with psychosis, delusions, patient believes that[she/he] is a federal investigator and stated that [she/he] "has a flamboyant disease which means that [she/he] has to wear high end clothing, "believes that [her/his] name is [Name Listed] per patient's mother, patient identifies as[Name] when[she/he] doesn't take[her/ his]medication, and says that many people are talking to [her/him] and presents with bizarre [sic] by marching around the house."

Physician: There were no physician interventions identified to address this problem.

Nurse: "Educate the pt. on the benefits and side effects of taking anti-psychotic medications to help manage symptoms of psychosis." This intervention did not contain the name of the medication that would address the patient's symptoms. This intervention or similarly worded intervention was also included in the treatment plans of patients A2, A3, A4, A5, A6, A8, A9, A10, A11, A12, and A13.

2. Patient A2's MTP, dated 6/14/19, included the following deficient interventions for the psychiatric problem: "Psychosis-BEH - Evidenced by: [Patient Name] admitted due to an increase in psychosis -patient appears catatonic and is demonstrating word salad. Patient has a history of hospitalizations."

Physician: "Evaluate the effectiveness of behavioral response to medication." This intervention statement was non-specific, not individualized, and a routine physician job function. There was no indication as to the behavioral response expected. This same or similarly worded intervention statements were also included for all active sample patients.

Nurse: Educate pt.[patient] on the benefits and side effects of taking [left blank] medication to help manage [left blank]." There was no indication as to the type of medication to educate the patient about nor what symptoms the nurse was going to help the patient manage.

3. Patient A3's MTP, dated 6/3/19, included the following deficient interventions for the psychiatric problem: "Psychoses with Fixed Delusions - Evidenced by: [Patient Name] was admitted for reported psychotic features (e.g. believes people are spreading rumors about[she/ him] and want to kill[she/ him], believes that [she/he] "exists to spread the truth "preoccupied with 'spiritcookers' and Hinduism, tangential speech and observed flight of ideas.) [Patient Name] was reportedly observed wandering around [her/his] neighborhood with no shirt or shoes on and report [she/he] was wandering because [her/his] cat was attacking [her/him]."

Physician: "Evaluate the effectiveness of behavioral response to medication." This intervention was non-specific, not individualized, and a routine function of the physician. This intervention did not identify medications to be utilized during treatment or describe the behavioral responses desired.

Nurse: "Educate the patient on the benefits and side effects of taking antipsychotic medication to help manage symptoms of mood." The problem identified did not indicate the patient had a problem with mood.

4. Patient A4's MTP, dated 6/10/19, included the following deficient interventions for the psychiatric problem: "Psychosis- BEH - Evidenced by: [Patient Name] is observed to be responding to internal stimuli. [Patient Name] is observed to be talking to [herself/himself]. [Patient Name] requires frequent redirection."

Physician: "Evaluate effectiveness of behavioral response to medication." This intervention was a generic and routine physician responsibility and did not indicate the medication to be used or the behavioral responses desired.

Nurse: "Educate pt. on the benefits and side effects of taking antipsychotic medication to help manage psychotic symptoms." This intervention did not list the name of the medication, nor did it indicate symptoms to be addressed.

5. Patient A5's MTP, dated 6/18/19, included the following deficient interventions for the psychiatric problem: "Psychosis with Aggression-BEH - Evidenced by: [Patient Name] was admitted with HI (Homicidal Ideation) toward person that sold [her/him] marijuana. Per ES [Patient Name] presents with bizarre behavior, tangential speech, makes odd comments and is aggressive with others."

Physician: "Evaluate effectiveness of behavioral response to medication." This intervention was a generic and routine physician responsibility and did not indicate medication to be used or the behavioral responses desired.

Nurse: "Educate pt. on benefits and side effects of [left blank] medication to help manage psychotic features." The name of the medication was not listed. Another nursing intervention was to "Evaluate the need for emergency psychotropic medication to relieve acute episodes." There was no description of what constituted an acute episode.

6. Patient A6's MTP, dated 4/30/19, included the following deficient psychiatric interventions for the problem: "Risk of Harm to Others/Aggression with impulsivity- BEH - Evidenced by: [Patient Name] threatened to burn down home and is verbally aggressive towards foster parent."

Physician: "Educate the patient on the benefits and side effects of taking medication and how it will help manage mood." The problem listed did not address mood.

Nurse: "Educate patient on the benefits and side effects of taking medication and how it will help manage mood." The medication name was not listed.

7. Patient A7's MTP, dated 6/14/19, included the following deficient psychiatric interventions for the problem: "Harm to self- BEH- Evidenced by [Patient Name] was admitted to [Name of Hospital]due to suicide risk attempt on 6/12/19 by setting the house on fire and reporting that [she/he] will use anything [she/he] can to attempt to harm[ herself/himself]."

Physician: "Evaluate pt. for effectiveness of medication." This intervention was a routine physician function. The intervention failed to include the name of the medication and what the physician would do to help the patient understand [her/his] psychiatric symptoms.

Nurse: "Educate patient on the benefits and side effects of taking anti-depressants and mood stabilizer to help manage depression and mood." The names of the medications were not listed.

8. Patient A8's MTP, dated 4/28/19, included the following deficient intervention for the psychiatric problem: "Risk for violence to Others/Threatening and Assaultive Behavior-BEH - Evidenced By . . . Prior to admission, [Patient Name] pushed [his/her] aunt during an argument and threatened to kill [her/his] family. Patient denies pushing aunt and reports that in fact [she] threatened [him/her]."

Physician: "Monitor a reduction in [Patient Name] violence and trauma related symptoms." This intervention was non-specific and failed to indicate how the physician was going to help the patient decrease violence and trauma symptoms. Another physician intervention was "Educate pt. on the benefits and side effects of taking mood stabilization medication and how it will help manage anger and aggression." This intervention did not indicate the medication to be used in the patient's education.

Nurse: "Educate pt. on the benefits and side effects of taking mood stabilization medication and how it will help manage anger and aggression." This intervention did not indicate the medication to be used.

9. Patient A9's MTP, dated 5/31/19, included the following deficient interventions for the problem "Harm to Self-BEH - Evidenced by: Per chart, Patient reports SI [Suicide Ideation] with a plan of harming [her/himself]by jumping on railroad tracks."

Physician: "Evaluate pt. for effectiveness of medication." This intervention statement was non-specific, a routine physician job function, and not individualized.

Nurse: "Educate the patient on the benefits and side effects of taking medication to help manage symptoms." This intervention did not list the medication, was non-specific, and was a routine nursing function.

10. Patient A10's MTP dated 5/29/19 included the following deficient interventions for the problem "Risk of Harm to Others/Aggression with Impulsivity - BEH- Evidenced by: [Patient Name] was aggressive before admission by throwing a dog against the wall and breaking both of its legs. Patient has a history of aggression and ADHD medication as well."

Physician: "Educate patient on the benefits and side effects of taking [Left Blank] medication and how it will help manage impulsive behaviors." The name of the medication was not listed. The intervention was non-specific and was a routine physician function.

Nurse: "Educate patient on the benefits and side effects of taking [Left Blank] medication and how it will help manage impulsive behaviors." The name of the medication was not listed. The nursing intervention was a routine nursing function and was non-specific.

11. Patient A11's MTP dated 6/21/19 included the following deficient interventions for the problem "Risk for Violence to Others/Threatening and Assaultive Behavior -BEH Evidenced by: [Patient Name] was admitted due to reported aggression towards[her/ his] grandmother (e.g. Tried to push grandmother down the stairs, made verbal threats and grabbed a knife threatening[her/ his] grandmother and stating "you are lucky to be alive")."

Physician: "Educate pt. on the benefits and side effects of taking ADHD [Attention Deficit Hyperactivity Disorder] and mood stabilization medications and how it will help manage mood. The name of the medication was not listed.

Nurse: "Educate pt. on the benefits and side effects of taking ADHD and mood stabilization medications and how it will help manage mood." The names of the medications were not listed.

12. Patient A12's MTP dated 12/19/19 included the following deficient intervention for the problem: "Harm to Self-BEH Evidenced by: [Patient Name] endorsed suicidal ideation with plan to hang self himself two weeks ago. [Patient Name] friend [ Friend Name] reported patient wrote suicide note. [Patient Name] reported history of one prior suicide attempt at age 15 or 16 via drinking draino."

Physician: "Evaluate pt. for effectiveness of medication." This intervention was a routine function of the physician.

Nurse: "Educate patient on the benefits and side effects of taking mood stabilizing medications to help manage suicidal ideation." This intervention was a routine function of nursing.

13. Patient A13's MTP dated 6/6/19 included the following deficient intervention for the problem: Psychosis-BEH Evidenced by: [Patient Name] was admitted due to psychosis-disorganization speech, bizarre statements, and responding to internal stimuli.

Physician: "Evaluate the effectiveness of behavioral response to medication." This intervention was a routine function of the physician.

Nurse: "Educate the pt. on the benefits and side effects of taking antipsychotic medication to help manage sx[symptoms] of psychosis. The name of the medication was not listed.

B. Staff Interview

1. In an interview on 6/26/19 at 9:30 a.m. with RN2, she agreed that the nursing interventions were generic and a routine function of the registered nurses.

2. In an interview on 6/27/19 at approximately 9:30 a.m., the Director of Nursing acknowledged that the nursing interventions in the EMR were generic and routine functions of the registered nurses.

C. Policy Review

The policy on "Interdisciplinary Treatment Planning Process" stated, "The plan shall describe patient strengths and disabilities: goals and specific treatment modalities." The facility did not consistently comply with this policy requirement.

Based on record review and interview, the facility failed to document treatment notes for active interventions listed on Master Treatment Plans assigned to registered nurses for 13 of 13 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13) and assigned to social work staff for 10 of 13 active sample patient (A2, A3, A4, A6, A7, A8, A10, A11, A12, and A13). Specifically, there was absent or limited documented evidence to show detailed and comprehensive information that included the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments if any. This failure hindered the treatment team in determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan in the event the patient did not respond to treatment interventions.

Findings include:

A. Record Review

The MTPs and documents regarding treatment notes were reviewed for the following patients were reviewed (admission and MTP dates in parentheses): A1 (4/27/19) - (4/29/19); A2 (6/3/19) - (6/6/19); A3 (6/1/19) - (6/3/19); A4 (6/8/19) - (6/10/19); A5 (6/16/19) - (6/18/19); A6 (4/30/19) - (4/30/19, last updated 6/25/19); A7 (6/12/19) - (6/14/19); A8 4/26/19) - (4/26/19); A9 (5/29/19) - (5/31/19); A10 (5/27/19) - (5/29/19); A11 (6/19/19) - (6/21/19); A12 (12/18/19) - (12/21/18); and A13 (6/6/19) - (6/7/19). This review revealed the following findings regarding treatment notes for the assigned treatment interventions to 1) registered nurses (RN) and 2) social work staff (SW) on the MTP.

1. RN Interventions

Thirteen (13) active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13 had the following identically or similarly worded RN intervention: "Educate pt. [Patient] on the benefits and side effects of taking anti-psychotic medication to help manage symptoms of [name of symptom]." The treatment modality was "1:1" or "Medication Education" and the frequency of contact was "1x per week." A review of the RN notes on the Electronic Medical Record from the admission date for each patient revealed no documentation that an RN met with these patients in individual sessions to provide medication education on a weekly basis. The only documented medication education was for the first dose the patient received. The facility submitted copies of the "Daily RN Reassessment Progress Note." These notes only provided documentation of the patient's behaviors and progress. However, there was no documentation about the number and duration of contacts with patients or any information regarding the medications discussed and how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

2. SW Interventions

a. Four active sample patients (A2, A3, A4, and A13) had the following identically or similarly worded SW intervention: "Help pt [patient] identify thought patterns not based in realty and discuss events and people." The treatment modality was "1:1" and the frequency of contact was "2x weekly for 20 minutes." A review of SW "Social Services Treatment Notes" from the admission date for each patient revealed that a SW met with these patients in individual sessions on a weekly basis to document the patients' progress. However, there was no documentation related to the number and duration of contacts with patients or any information provided patients regarding helping them to identify thought patterns not based on reality or discussing real events and people. There was no recorded information regarding how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

b. Six active sample patients (A6, A7, A8, A10, A11, and A12) had the following identically or similarly worded SW intervention: "Teach pt. [Patient] to develop safe ways to manage feelings/thoughts through: dancing, reading, writing ..." The treatment modality was "1:1" and the frequency of contact was "2x weekly for 20 minutes." A review of SW "Social Services Treatment Notes" from the admission date for each patient revealed that an SW meets with these patients in individual sessions on a weekly basis to document the patients' progress. However, there was no documentation related to the number and duration of contacts with patients or any information provided to patients regarding safe ways to manage thoughts and feeling. There was no recorded information regarding how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

c. Patient A3 also had the following SW intervention: "Provide education regarding diagnosis, medication management and recommendations for outpatient support services to ensure compliance with aftercare." The treatment modality was "1:1" and the frequency of contact was "2x weekly for 20 minutes." A review of SW "Social Services Treatment Notes" from the admission date for each patient revealed that an SW meets with these patients in individual sessions on a weekly basis to document the patients' progress. However, there was no documentation related to the number and duration of contacts with patients or any information provided patients regarding helping them to identify thought patterns not based on reality or discussing real events and people. There was no recorded information regarding how the patient responded to the interventions, including the level of participation, behaviors exhibited, and specific comments made during interventions.

B. Interviews

1. In an interview on 6/27/19 at 9:30 a.m., the Director of Nursing did not dispute the findings that nursing interventions on the MTPs were not documented as being provided on a weekly basis.

2. In an interview on 6/27/19 at 9:25 a.m., the Director of Social Worker agreed that the social work progress notes did not include documented evidence that interventions on treatment plans were implemented to reflect information or teaching provided by social work staff. She also acknowledged that there was no documented evidence regarding the patient's response to treatment interventions.

Based on record review and interview, the Medical Director failed to adequately monitor the care provided to the patients at the facility. Specifically, the Medical Director failed to:

I. Develop individualized Master Treatment Plans (MTPs) that identified long and short-term goals stated in observable, measurable patient behaviors to be achieved for 13 of 13 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). The facility also failed to ensure that goals were consistently written in language understandable to patients and free of psychiatric jargon. Due to the lack of individualized symptoms, specific descriptors, and observable behaviors on the MTPs, it would be difficult to assess the effectiveness of treatment and to implement possible changes. (Refer to B121).

II. Provide 12 of 13 active sample patients (A1, A2, A3, A4, A5, A7, A8, A9, A10, A11, A12, and A13) with Master Treatment Plans (MTPs), which included individualized active interventions that stated specific treatment modalities with a specific focus or purpose based on each patient's identified problems. This deficiency results in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or effective treatment. (Refer to B122-I).

III. Identify Master Treatment Plans (MTPs) that identified interventions that were specific to the patient's problems for thirteen (13) of thirteen (13) active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). The Master Treatment Plan contained predetermined interventions that were in the Electronic Medical Record (EMR). The interventions were routine generic functions of these disciplines rather than active treatment interventions for the identified problems listed in the treatment plan. The facility failed to identify treatment interventions that provided a focus that addressed each patient's individual needs and resulted in failure to guide treatment staff to achieve measurable, behavioral outcomes. (Refer B122-II).

Based on record review and interview, the Director of Nursing failed to monitor and take corrective action to ensure that:

I. Individualized Master Treatment Plans (MTPs) contained long and short-term goals stated in observable, measurable patient behaviors to be achieved for 13 of 13 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). Due to the lack of individualized symptoms, specific descriptors, and observable behaviors on the MTPs, it would be difficult to assess the effectiveness of treatment and to implement possible changes. (Refer to B121).

II. MTPs identified nursing interventions that were specific to the patient's problems for thirteen (13) of thirteen (13) active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). The Master Treatment Plan contained predetermined interventions that were in the Electronic Medical Record (EMR). The interventions were routine generic nursing functions rather than active treatment interventions for the identified problems listed in the treatment plan. The facility failed to identify treatment interventions that provided a focus that addressed each patient's individual needs and resulted in failure to guide treatment staff to achieve measurable, behavioral outcomes. (Refer B122-II).

III. Medical records contained treatment notes for active interventions listed on Master Treatment Plans assigned to registered nurses for 13 of 13 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, and A13). Specifically, there was absent or limited documented evidence to show detailed and comprehensive information that included the patients' attendance or non-attendance, specific topics discussed, the patients' behavior during interventions, and their response to interventions, including the level of participation, understanding of the information provided, and specific comments, if any. This failure hindered the treatment team in determining the patient's response to active treatment interventions, evaluating if there were measurable changes in the patients' condition, and revising the treatment plan when the patient did not respond to treatment interventions. (Refer to B124).