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Based upon a review of records, documents, and interviews with staff and patients, the facility failed to:

I. Document a full psychosocial assessment for three (3) of eight (8) active sample patients (A2, A3, and A4). Psychosocial assessments were incomplete and lacked a summary of findings, the anticipated social work role in treatment and discharge planning, as well as areas of special risk requiring immediate intervention. This failure to comprehensively assess the patient's psychosocial needs potentially resulted in suboptimal inpatient progress and/or inadequate discharge care plans. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed in restraint (manual hold). Specifically, for one (1) of eight (8) active sample patients (A3), the MTP was not revised to reflect problem statements related to the use of restraint to control aggressive behavior, treatment goals, and active treatment interventions outlining healthy alternatives and approaches for the patient to use to replace aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

III. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the MTPs did not include:

(1) Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119)

(2) Observable and measurable short-term goals written in behavioral terms. (Refer to B121).

(3) Specific individualized active treatment interventions (Refer to B122). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

IV. Ensure that active treatment interventions listed on the treatment plan and/or unit schedule were documented in the medical record to include the patients' attendance or non-attendance, specific topics discussed, and the patients' behavior during group, and their response to the group intervention, including level of participation, understanding, and specific comments. This included groups assigned to activity therapy staff, recovery specialists, and nurses for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8. This failure hindered the treatment team from 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)

IV. Ensure that active treatment groups were provided for seven (7) of eight (8) active sample patients (A1, A2, A3, A5, A6, A7 and A8). Specifically, therapeutic group modalities were often not held, poorly attended, and/or failed to provide treatment based upon a patient ' s individually assessed needs. This failure potentially resulted in care, which was generic as well as sub-optimal patient outcomes. (Refer to B125-I)

V. Appropriately evaluate and document episodes of restraint for one (1) of eight (8) active sample patients (A3) and six (6) of four (4) non-sample patients (R1, R4, R5 and R6) whose records were selected to review episodes of seclusion and restraint. Specifically, none of the five (5) patients had a documented one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements and facility policy. One non-sample patient (R5) sustained an injury serious enough to require transfer to a medical facility after an episode of restraint. In addition, there was no documentation provided by the facility of a subsequent revision of the MTP for patient A3. These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to the patient. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients. (Refer to B125-II)

Based upon a review of records and staff interview, the facility failed to document a full psychosocial assessment for three (3) of eight (8) active sample patients (A2, A3, and A4). Per the Director of Medical Records and the facility's policy, the Psychosocial Evaluation was contained in the Emergency Evaluation document, which was completed at the time of a patient's initial intake assessment. Some psychosocial assessments were incomplete and none provided a summary of findings, the anticipated social work role in treatment and discharge planning, nor described areas of special risk or concern for the patient. This failure to comprehensively assess the patient's psychosocial needs potentially resulted in suboptimal inpatient progress and/or inadequate discharge care plans.

Findings include:

A. Record Review

1. Patient A2 was admitted 10/31/15 with a diagnosis of Schizoaffective Disorder. The Preliminary Psychosocial section of the Emergency Evaluation document recorded the following: "History retrieved from previous evaluation: Patient reported (s/he) is the only child. No developmental issues reported graduated high school on target. Attended college but stopped going due to (his/her) mental health issues. Never been married, no children, not working. No legal issues." The section titled: "Interpretive Summary and Disposition," contained only the following reference to the patient's assessed psychosocial needs: "(S/he) reports that (s/he) has very limited social support but that (s/he) can talk to (his/her) brother sometimes." No information pertinent to anticipated necessary steps for discharge to occur, high-risk patient and/or family psychosocial issues requiring early treatment planning/immediate interventions, specific community resources/support systems for utilization in discharge planning, nor anticipated social work role(s) in treatment and discharge planning was recorded in this document.

2. Patient A3 was admitted 11/7/2015 with a diagnosis of Disruptive Mood Regulation Disorder. The Preliminary Psychosocial section of the Emergency Evaluation document recorded the following: "Unable to access (sic) due to fast track and confused behavior." The Spiritual Assessment section noted: "Person unk [sic] feels guilty over past behaviors. Anger or resentment unk blocks person's peace of mind. Person unk feels that life has no meaning or purpose. Person unk feels unfairly treated by God/Life. Person unk feels hopelessness, despair, or grief." No information pertinent to anticipated necessary steps for discharge to occur, high risk patient and/or family psychosocial issues requiring early treatment planning and immediate interventions, specific community resources/support systems for utilization in discharge planning, nor anticipated social work role(s) in treatment or discharge planning was recorded in this document.

3. Patient A4 was admitted 11/15/15 with a diagnosis of Schizophrenia. The Preliminary Psychosocial section of the Emergency evaluation document recorded the following: "(Spouse) reports patient was born in Philadelphia PA to an intact family. (S/he) denies any developmental issues and report (s/he) achieved her developmental milestones at appropriate times. (His/her) (Spouse) reports that (s/he) has a HS diploma. (Spouse) reports that (s/he) was previously a beautician." The Spiritual Assessment section noted: "Person unk feels guilty over past behaviors. Anger or resentment unk [sic] blocks person's peace of mind. Person unk feels unfairly treated by God/Life. Person unk feels hopelessness, despair, or grief." No information pertinent to anticipated necessary steps for discharge to occur, high risk patient and/or family psychosocial issues requiring early treatment planning and immediate interventions, specific community resources/support systems for utilization in discharge planning, nor anticipated social work role(s) in treatment and discharge planning was recorded in this document.

B. Staff Interview

In an interview held in the Administrator's Conference Room on 11/16/15 at 3:00 p.m., the Director of Social Services acknowledged the deficiencies in the records of sample patients A1, A2, and A3. He further affirmed that no formal process for completion of psychosocial assessments existed after the patient was admitted and that none of these assessments included a summary of assessed psychosocial needs nor a review of specific areas of concern for risk mitigation post-discharge. He acknowledged that the facility employed no licensed social workers or Master's prepared clinicians who performed social work functions on the treatment units. He was similarly unable to interpret the Spiritual Assessments for Patients A3 and A4 stating: "These must be mistakes."

I. Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the MTPs did not include:

(1) Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119)

(2) Observable and measurable short-term goals written in behavioral terms. (Refer to B121)

(3) Specific individualized active treatment interventions. (Refer to B122)

Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

II. Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) were revised when patients were placed in seclusion or restraint. Specifically, for one (1) of eight (8) active sample patients (A3), MTPs were not revised to reflect problem statements related to the use of restraint to control aggressive behavior, identification of treatment goals and interventions outlining healthy alternatives and approaches for patients to use to replace aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients.

Findings include:

A. Record Review

Patient A3 was restrained on 11/9/15 after an episode of agitation at 5:04 p.m. on 11/9/15 per an entry in the nursing progress note. The "Mechanical/Chemical Restraint Order Sheet" indicated that a manual hold was required to administer Zyprexa 10 mg IM due to behavior of agitation. The MTP dated 11/7/15 was not revised to reflect a problem statement regarding the use of a restraint procedure, treatment goals, and interventions to reflect alternatives to restraint and approaches the patient could use to replace aggressive behaviors).

B. Policy Review

A review of the facility's policy titled "Special Treatment Procedures-Restraints" contained no provisions to revise the Master Treatment Plan after an episode of seclusion or restraint in accordance with CMS requirements.

Based on record review and staff interviews, the facility failed to ensure that each patient had individualized psychiatric problem statements written in behavioral and descriptive terms on Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Instead, the stated problems on the treatment plans included diagnoses and/or generalized lists of statements or symptoms, rather than behaviorally descriptive clinical information based on patients' presenting symptoms which had to be resolved or reduced prior to discharge. This failure potentially hampers the treatment team's ability to determine patients' response to treatment interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Record review

1. The MTP for Patient A1 dated 11/11/15 had the following psychiatric problem statement: Problem #1 - "Ineffective coping." Although there was baseline information documenting, "[Patient's name] has been having difficulty coping recently and has lost [his/her] job 3 weeks ago, the problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested "ineffective coping." The patient's psychiatric evaluation dated 11/12/15 documented the following descriptive information: "[Patient's name] reports depressive symptoms and panic attacks. [S/he] reports [s/he] has fear of his living environment due to an attack last October that occurred in [his/her] front yard...[S/he] asserts 'A 52 year old [gender] should be able to have a conversation without crying'...[S/he] reports nightmares about [his/her] attack in October 2014..."

2. Patient A2's MTP dated 11/1/15 had the following psychiatric problem statement: Problem #1 - "Speech, behavior, or reports indicating significant danger to self." The problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested "danger to self." The patient's psychiatric evaluation dated 11/1/15 documented the following descriptive information: "...'We have received multiple calls regarding the subject exposing [him/herself] and jumping in front of vehicles...' [Patient's name] reports auditory hallucinations that are command in nature..."

3. Patient A3's MTP dated 11/7/15 had the following psychiatric problem statements: Problem #1 - "Bullying or threatening behaviors." Problem #2 - "Violence risk: directed towards other." These problem statements failed to include behaviorally descriptive clinical information to show how this patient precisely manifested "bullying or threatening behavior or Violence risk." The patient's psychiatric evaluation dated 11/8/15 documented the following descriptive information: "...physically abusive towards [his/her] [spouse]...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..."

4. Patient A4's MTP dated 11/15/15 had the following psychiatric problem statement: Problem #1 - "Violence risk: directed towards other." This problem statement failed to include behaviorally descriptive clinical information to show how this patient precisely manifested "Violence risk." The patient's psychiatric evaluation dated 11/16/15 documented the following descriptive information: "...[S/he] will then go outside and shout at neighbors calling them names and shouting insults...[s/he] aggressively approaches multiple strangers loudly and inappropriately comments on their physical appearance..."

5. Patient A5's MTP dated 11/8/15 had the following psychiatric problem statements: Problem #1 - "Substance abuse / chemical dependency." Problem #2 - "Speech, behavior, or reports indicating significant danger to self." Problem #3 - "Auditory, visual, or tactile hallucinations resulting in impaired functioning." These problem statements failed to include behaviorally descriptive clinical information to show how this patient precisely manifested substance abuse, danger to self, and hallucinations. The patient's psychiatric evaluation dated 11/9/15 documented the following descriptive information: "... [Patient's name] has threatened to shoot [him/herself] and is violent toward others. [Patient's name] was also observed to throw objects at family members...[Family member's name] reports that [Patient's name] used many drugs but [his/her] drug of choice seems to be crack cocaine...[Patient's name] has expressed visual hallucination as well as stating [s/he] sees bugs crawling on the walls and seeing people who are not there..."

6. Patient A6's MTP dated 11/3/15 had the following psychiatric problem statements: Problem #1 - "Non-compliance with medical or other recommended treatments resulting in decompensation." Problem #2 - "Medication management." Problem #3 - "Depressed mood." These problem statements failed to include behaviorally descriptive clinical information to show how this patient precisely manifested non-compliance, medication issues, and depressed mood. The patient's psychiatric evaluation dated 11/4/15 documented the following descriptive information: "...presumptive positive for Benzodiazepine...Client reported [s/he] took [his/her] mother medications, [s/he] states, 'I took 4 Xanax and 2 Vicodin' unknown dosages...[S/he] reports [s/he] is hearing a voice telling [him/her] to take [his/her] mother's medications and kill [him/herself]...Client reports multiple suicidal attempts in the past. [S/he] reports taking 175 multiple pills which lead to [him/her] being hospitalized..."

7. Patient A7's MTP dated 10/12/15 had the following psychiatric problem statements: Problem #1 - "Medication Management." Problem #2 - "Agitated behavior which client is unable to control." These problem statements failed to include behaviorally descriptive clinical information to show how this patient precisely manifested medication issues and agitated behavior. The patient's psychiatric evaluation dated 10/13/15 documented the following descriptive information: "...[Patient's name] is fixated on paranoid thoughts that others, including [his/her] son, are stealing [his/her] money...reports that this boyfriend has been stealing [his/her] medications and [his/her] Cogentin is missing completely...reports that [s/he] missed [his/her] last Invega injection that was due 10/6/15..."

8. Patient A8's MTP dated 11/12/14 had the following psychiatric problem statements: Problem #1 - "Violence risk: directed towards self." Problem #2 - "Ineffective coping." Problem #3 - " Speech, behavior, or reports indicating significant danger to self. " These problem statements failed to include behaviorally descriptive clinical information to show how this patient precisely manifested dangerousness to self and ineffective coping. The patient's psychiatric evaluation dated 11/12/15 documented the following descriptive information: "...Paperwork accompanying individual from the hospital reports that [s/he] took 10-15 pills of 500 mg. penicillin because [s/he] felt like [his/her] family did not want [him/her] to live there...[his/her] mother told nurse that [Patient's name] attempted to kill [him/herself] with a knife 2 days ago...[S/he] reports severe issues with housing and moderate issues with employment..."

B. Staff Interviews

1. In an interview on 11/17/15 at 10:35 a.m., with the Activities Director, MTPs were reviewed. She acknowledged that problem statements were not descriptive of each patient's presenting symptoms.

2. In an interview on 11/17/15 at 1:40 p.m., with the Lead Recovery Specialist, MTPs were discussed. She agreed that problem statements were not descriptive of each patient's presenting problem.

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) that identified individualized patient-related short-term goals (called objectives by the facility) stated in observable, measurable, and behavioral terms. Short-term goal (STG) statements did not include what the patient would do to lessen the severity of problems identified on admission. In addition, the STGs did not define patient outcomes or areas of patient improvement, were not specific, or described routine hospital functions performed by clinical staff. Failure to identify individualized goals potentially hampers the treatment team's ability to determine whether the treatment plan is effective and if it needs to be revised.

Findings include:

A. Record Review

The treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (11/11/15); A2 (11/1/15); A3 (11/7/15); A4 (11/15/15); A5 (11/8/15); A6 (11/3/15); A7 (10/12/15); and A8 (11/12/15). This review revealed the following deficient short-term goals (STG) for psychiatric problems. Several STG statements were identical despite each patient's different problems and presenting symptoms.

1. Patient A1's MTP listed the following STG for the problem of "Ineffective coping."

Objective 1.1: "Evaluate need for psychiatric medications/consults/referrals." This STG described a routine staff function and was not written as a patient oriented goal that included the action statement(s) regarding the patient's understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge.

Objective 1.2: "Client will write down one way in which [s/he] maintains a poor self image and identify one alternative coping strategies." There was nothing found in the clinical assessments that was descriptive of Patient A1's "poor self image" therefore it was difficult to discern how staff would determine whether the patient had achieve this STG.

2. Patient A2's MTP listed the following STGs for the problem of "Speech, behavior, or reports indicating significant danger to self."

Objective 1.1 - "Client will not harm self/others while in hospital."
The STG was not stated in behavioral and specific terms with positive alternative or replacement behavior that would show the patient ' s increased level of functioning.

Objective 1.3 - "Make appropriate referrals for service/placement prior to d/c [discharge]." This STG was a routine hospital function performed by clinical staff and was not a specific behavioral and measurable patient outcome statement.

3. Patient A3 ' s MTP listed the following deficient goal statements for the problem of " Bullying and threatening behaviors. "

Objective 1.1 - "Administer medications and monitor medication compliance." This STG was a routine hospital function performed by licensed nurses. There was no patient outcome statement reflecting action statement(s) regarding the patient's understanding about his or her medications (benefits, side effects), reasons for compliance, and the need for compliance during hospitalization and after discharge.

Objective 1.2 - "Client will not harm others or self while in hospital." This short-term goal was a staff expectation to maintain patient safety, however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the harmful thoughts/impulses to others or self. The STG was not stated in behavioral terms reflecting what the patient would be doing or saying to reduce harmful thoughts/impulses. For problem 2 of "Violence risk: directed toward others," the following STG statement was included on the MTP.

Objective 2.2 - "Make appropriate referrals for services/placement prior to d/c [discharge]." This STG a routine hospital function performed by clinical staff and was not a specific behavioral and measurable patient outcome statement.

4. Patient A4's MTP listed the following STG statement for the problem of "Violence risk: directed toward others."

Objective 1.1 - "Client will not harm others or self while in hospital." This short-term goal was a staff expectation required to maintain patient safety, however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the harmful thoughts/impulses to other or self.

5. Patient A5's MTP listed the following STG statements:

a. For problem #2 of "Speech, behavior, or reports indicating significant danger to self:"

Objective 2.2 - "Client will not verbalize suicidal ideas when questioned by staff for three consecutive days." This short-term goal was a staff expectation to maintain patient safety, however did not include direct positive action behavior(s) that the patient would achieve to replace, lessen, and/or eliminate the suicidal thoughts/impulses.

Objective 2.3 - "Evaluate need for psychiatric medications/consults/referrals." This STG was a routine hospital function performed by clinical staff and was not written as a patient oriented goal that included the action statement(s) regarding the patient's understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge.

Objective 2.4 - "Make appropriate referrals for services/placement prior to d/c [discharge]." This STG was a routine hospital function performed by clinical staff and was not a specific behavioral and measurable patient outcome statement.

b. For problem #3 - "Auditory, visual, or tactile hallucinations resulting in impaired functioning."

Objective 3.1 - "Client will be oriented in all spheres." There was no specific STG related to direct positive action behavior(s) that the patient would achieve to replace and lessen hallucinations to perform activities of daily living despite of hallucinations.

6. Patient A6's MTP listed the following STG statements:

a. For problem #1: "Non-compliance with medical or other recommended treatments resulting in decompensation."

Objective 1.2 - "Practice healthy coping skills." This STG was not specifically related to non-compliance. There was no STG statement reflecting patient outcomes related to compliance with medical or recommended treatments.

b. For problem #2: "Medication Management."

Objective 2.1 - "Take the medications responsibly on a single, day to day basis." This STG was a staff expectation and was not written as a patient oriented goal that included the action statement(s) regarding the patient's understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge.

c. For problem #3: "Depressed mood."

Objective 3.1 - "Client will describe one problem behavior and related [sic] it to a mood and thought." This STG statement was a first step to be taken related to the patient's gaining understanding of his or her depressed mood. However, there was no patient outcome statement regarding what the patient would be doing and/or saying to show replacement behaviors to lessen of the severity of presenting problems related to depressed mood.

Objective 3.3 - "Make appropriate referrals for services/placement prior to d/c [discharge]." This STG was a routine hospital function performed by clinical staff and was not a specific behavioral and measurable patient outcome statement.

7. Patient A7's MTP listed the following STG statements:

a. For problem #1: "Medication management."

Objective 1.1 - "Take the medications responsibly on a single, day to day basis." This STG was a staff expectation and was not written as a patient oriented goal that included the action statement(s) regarding his/her understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge.

Objective 1.2 - "Practice healthy coping skills." This STG was not specifically related to non-compliance. There was no goal statement reflecting patient outcomes related to compliance with medical or recommended treatments.

b. For problem #2: "Agitated behavior which client is unable to control."

Objective 2.1 - "Make appropriate referrals for services/placement prior to d/c [discharge]." This STG was a routine hospital function performed by clinical staff.

Objective 2.2 - "To function for one entire day without anxiety, agitation, or obsessive doubts." This was a staff expectation. There was no specific STG related to direct positive action behavior(s) that the patient would achieve to replace and lessen agitated behavior.

8. Patient A8's MTP listed the following STG statements:

a. "Violence risk: directed toward others," the following deficient STG statement was included on the MTP.

Objective 1.1 - "Client will not harm self/others while in hospital"

The STG was not stated in behavioral and specific terms with positive alternative or replacement behaviors that would show the patient's increased level of functioning. This STG was identical for Patients A2, A3 and A4 despite different present symptoms and needs.

b. For problem #2: "Ineffective coping" the following STG statement was included on the MTP.

Objective 2.1: "Evaluate need for psychiatric medications/consults/referrals." This STG was a routine hospital function performed by clinical staff especially the psychiatrist and was not written as a patient oriented goal that included the action statement(s) regarding his/her understanding about medications (benefits, side effects), reasons for compliance and the need for compliance during hospitalization and after discharge. This identical STG was also included on Patients A1's and A5's MTP. Therefore, the STG statement was not individualized to reflect each patient's specific need regarding medications.

c. For problem #3: "Speech, behavior, or reports indicating significant danger to self."

Objective 3.2 - "Make appropriate referrals for services/placement prior to d/c [discharge]." This STG was a routine hospital function performed by clinical staff. The identical STG statement was also included on Patients A2's, A3's, A5's, A6's and A7's MTP. Therefore, the STG was not individualized to reflect patient outcomes based on each patient's presenting symptoms and needs for referrals and discharge placement.


B. Staff Interviews

1. In an interview on 11/17/15 at 10:35 a.m., with the Activities Director, MTPs were reviewed. She acknowledged that the treatment goals were not specific patient oriented goals.

2. In an interview on 11/17/15 at 10:20 a.m., RN4 acknowledged that some goal statements were related to staff expectations and routine nursing tasks instead patient outcome statements.

3. In an interview on 11/17/15 at 1:40 p.m., with the Lead Recovery Specialist, MTPs were discussed. She acknowledged that some objectives were hospital functions or staff expectations and were not stated as patient outcomes.

Based on observation, record review, document review, and interview, the facility failed to provide eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) with Master Treatment Plans (MTPs) that included individualized active treatment interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Specifically, MTPs: (a) included routine discipline functions selected from options on the facility's electronic medical record. These options stated as treatment interventions were generic, vague, and global statements without an identified method of delivery; (b) included no interventions related to psychiatric problems identified to be implemented by the attending psychiatrist for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), no RN interventions for five (5) of eight (8) active sample patients (A2, A4, A6, A7 and A8); no activity therapy interventions for two (2) of eight (8) active sample patients (A4 and A8); and no social work intervention identified for two (2) of eight (8) active sample patients (A1, and A4); and (3) failed to include a nurse led group on the treatment plan that was listed on the unit schedule and attended by three (3) of eight (8) active sample patients (A5, A6 and A7). These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

I. Failure to include individualized treatment intervention

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (11/11/15); A2 (11/1/15); A3 (11/7/15); A4 (11/15/15); A5 (11/8/15); A6 (11/3/15); A7 (10/12/15); and A8 (11/12/15). This review revealed that the MTPs included but not limited to the following routine and generic statements (such as evaluating, administering medications, monitoring, and encouraging) and/or other generic discipline functions written as treatment interventions to be delivered by registered nurses (RN) and social workers (SW) [recovery specialists]. Several intervention statements were identical or similarly worded.

1. Patient A1 had the following generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/12/15 documented that, "[Patient's name] reports depressive and panic attacks. [S/he] reports [s/he] has fear of his living environment due to an attack last October that occurred in [his/her] front yard...[S/he] asserts 'A 52 year old [gender] should be able to have a conversation without crying'...[S/he] reports nightmares about [his/her] attack in October 2014." The interventions identified for the following problem included:

Problem #1 - "Ineffective coping."

RN Interventions: "Encourage individual to discuss current life situations."

Rehabilitation (Activity Therapy): "Motivational Enhancement Therapy."

There was no intervention related to psychiatric problems identified to be implemented by the attending psychiatrist and by the social worker (recovery specialist).

The RN intervention above was a routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. The activity therapy intervention statement also failed to include the focus of individual treatment based on the patient's needs and presenting clinical history. These intervention statements failed to include whether the intervention would be delivered in individual or group sessions.

2. Patient A2 had the following generic and/or routine discipline function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/1/15 documented that, "...'We have received multiple calls regarding the subject exposing [him/herself] and jumping in front of vehicles...' [Patient's name] reports auditory hallucinations that are command in nature." The interventions identified for the following problem included:

Problem #1 - "Speech, behavior, or reports indicating significant danger to self."

SW Interventions (Recovery Specialist): "Identify behavior of violence toward self and place on precautions." "Monitor behavior of violence towards self as it occurs." "Medication/Consults/Referrals."

Rehabilitation (Activity Therapy): "Motivational Enhancement Therapy."

There was no interventions related psychiatric problems identified to be implemented by the attending psychiatrist and by the registered nurse.

The recovery specialist interventions above were routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. The intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist. The activity therapy intervention statement also failed to include the focus of individual and/or group contact based on the patient's needs and presenting clinical history. These intervention statements failed to include whether the intervention would be delivered in individual or group sessions.

3. Patient A3 had the following generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/8/15 documented that, "...physically abusive towards [his/her] [spouse]...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..." The interventions identified for the following problems included:

a. Problem # 1: "Bullying or threatening behaviors."

LPN Intervention: "Medication/Consults/Referrals: Outpatient therapy for medication management/problem solving."

SW (Recovery Specialist): "Psychoeducation."

b. Problem #2: "Violence risk: directed towards other."

RN Intervention: "Medications/Consults/Referrals."

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

There were no interventions related psychiatric problems identified to be implemented by the attending psychiatrist.

The nursing interventions above were routine staff functions and not specific patient outcome statements related to the patient's improvement. There was no active treatment intervention regarding the RN assisting and/or teaching the patient non-harmful ways of dealing with aggressive behavior. In addition, there was no active treatment intervention regarding the RN and LPN assisting the patient to understand prescribed medications including the benefits of medications and need to continue them after discharge. The interventions related to "Psychoeducation" and "Motivational Enhancement Therapy" did not include a focus of treatment based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions).

4. Patient A4 had the following generic and/or routine discipline function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/16/15 documented that, "...physically abusive towards [his/her] [spouse]...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..." The intervention identified for the following problem included:

Problem # 1: "Violence risk: directed towards others."

LPN Interventions: "Monitor behavior of violence towards other as it occurs."

There were no interventions related to the psychiatric problem identified to be implemented by the attending psychiatrist, the registered nurse, recovery specialist, and rehabilitation (activity therapists).

The nursing intervention above was a routine staff functions and not a specific patient outcome statement related to the patient's improvement. There was no active treatment intervention reflecting how the RN or LPN would assist and teach the patient non-harmful ways of dealing with aggressive behavior. The intervention statement failed to include a method of delivery (individual or groups sessions).

5. Patient A5 had the following generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/9/15 documented that, "...[Patient's name] has threatened to shoot [him/herself] and is violent toward others. [Patient's name] was also observed to throw objects at family members...[Family member's name] reports that [Patient's name] used many drugs but [his/her] drug of choice seems to be crack cocaine...[Patient's name] has expressed visual hallucination as well as stating [s/he] sees bugs crawling on the walls and seeing people who are not there..." The interventions identified for the following problems included:

a. Problem # 1: "Substance abuse / chemical dependency."

RN Intervention: "Urge the patient to accept personal responsibility for substance abuse and consequent erratic behavior." Although there was no staff responsibility identified, the Lead Recovery Specialist stated that this was a nursing intervention, during an interview on 11/17/15 at 1:40 p.m.

SW (Recovery Specialist): "Motivational Enhancement Therapy."

b. Problem #2: "Speech, behavior, or reports indicating significant danger to self."

SW (Recovery Specialist): "Motivational Enhancement Therapy." "MedTEAM (Medication, Treatment, Evaluation, Management)."

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

c. Problem #3: "Auditory, visual, or tactile hallucinations resulting in impaired functioning."

SW (Recovery Specialist): "Motivational Enhancement Therapy."

There were no interventions related to psychiatric problems identified to be implemented by the attending psychiatrist. This MTP contained the same staff member listed for each intervention. During interview on 11/17/15, the Lead Recovery Specialist reported that the staff identified on the MTP was a recovery specialist.

The nursing intervention above was a routine staff functions and not a specific patient outcome statement related to the patient's improvement. There was no specific active treatment intervention reflecting information the RN would provide regarding substance abuse based on presenting symptoms and needs. The intervention statement failed to include a method of delivery (individual or groups sessions). Most of the interventions were identified to be "Motivational Enhancement Therapy." This intervention statement did not include a focus of treatment based on the patient's presenting symptoms and also did not include a method of delivery (individual or groups sessions).

6. Patient A6 had the following generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/4/15 documented that, "...presumptive positive for Benzodiazepine...Client reported [s/he] took [his/her] mother medications, [s/he] states, 'I took 4 Xanax and 2 Vicodin' unknown dosages...[S/he] reports [s/he] is hearing a voice telling [him/her] to take [his/her] mother's medications and kill [him/herself]...Client reports multiple suicidal attempts in the past. [S/he] reports taking 175 multiple pills which lead to [him/her] being hospitalized..." The interventions identified for the following problems included:

a. Problem # 1: "Non-compliance with medical or other recommended treatments resulting in decompensation."

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

b. Problem #2: "Medication management."

LPN Intervention: "Monitor the clients use of expected benefit of the medications."

c. Problem #3: "Depressed mood."

SW (Recovery Specialist): "Motivational Enhancement Therapy." This intervention was identified for all three objectives listed for depressed mood.

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

There was no interventions related psychiatric problems identified to be implemented by the attending psychiatrist and registered nurse.

The nursing intervention above was a routine nursing functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to understand prescribed medications including the benefits of medication and need to continue medications after discharge. The intervention related to "Motivational Enhancement Therapy" did not include a focus of treatment based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions).

7. Patient A7 had the following generic and routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 10/13/15 documented the following descriptive information: "...[Patient's name] is fixated on paranoid thoughts that others, including [his/her] son, are stealing [his/her] money...reports that this boyfriend has been stealing [his/her] medications and [his/her] Cogentin is missing completely...reports that [s/he] missed [his/her] last Invega injection that was due 10/6/15..." The interventions identified for the following problems included:

a. Problem #1: "Medication management."

LPN Intervention: "Monitor the clients use of expected benefit of the medications."

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

b. Problem #2: "Agitated behavior which client is unable to control."

SW (Recovery Specialist): "Psychoeducation." "Medications/Consults/Referrals." "MedTEAM (Medication, Treatment, Evaluation, Management."

Rehabilitation (Activity Therapist): "Motivational Enhancement Therapy."

There was no interventions related psychiatric problems identified to be implemented by the attending psychiatrist and registered nurse.

The nursing intervention above was a routine nursing function and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to understand prescribed medications including the benefits of medication and need to continue medications after discharge. The interventions related to "Psychoeducation" and "Motivational Enhancement Therapy" were vague, global, and did not include a focus of treatment based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions). he intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist.

8. Patient A8 had the following generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/12/15 documented that, "...Paperwork accompanying individual from the hospital reports that [s/he] took 10-15 pills of 500 mg. penicillin because [s/he] felt like [his/her] family did not want [him/her] to live there...[his/her] mother told nurse that [Patient's name] attempted to kill [him/herself] with a knife 2 days ago...[S/he] reports severe issues with housing and moderate issues with employment,..." The interventions identified for the following problems included:

a. Problem #1: "Violence risk: directed towards self."

LPN Intervention: "Maintain and convey a calm attitude."

b. Problem #2: "Ineffective coping."

LPN Intervention: "Encourage individual to discuss current life situations."

c. Problem #3: "Speech, behavior, or reports indicating significant danger to self."

SW (Recovery Specialist): "Medications/Consults/Referrals."

There was no interventions related psychiatric problems identified to be implemented by the attending psychiatrist, registered nurse and activity therapist.

The nursing interventions above were routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to deal suicidal thoughts and behaviors. In addition, there was no active treatment intervention regarding the RN and LPN and other clinical staff would assist the patient to identify healthier coping strategies to use when feeling suicidal. The intervention related to medications was vague, global, and did not include a focus of treatment based on the patient's presenting symptoms. The intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist. None of the intervention statements included a method of delivery (individual or groups sessions).

B. Staff Interviews

1. In an interview on 11/17/15 at 10:35 a.m., with the Activities Director, MTPs were reviewed. She acknowledged that the treatment intervention were vague and global. She stated she could not explain what was included in "Motivational Enhancement Therapy" and reported, "We were told to select that intervention."

2. In an interview on 11/17/15 at 10:20 a.m., RN4 acknowledged that nursing interventions were not individualized and were routine nursing functions that would be provide to any patient regardless of presenting symptoms.

3. In an interview on 11/17/15 at 1:40 p.m., with the Lead Recovery Specialist, MTPs were discussed. She acknowledged the intervention related to "Motivational Enhancement Therapy" was very broad and did not contain an individualized focus of active treatment based on each patient's presenting symptoms.

II. Failure to Include a Group Attended by Patients on the Master Treatment Plan

A. Document Review and Observations

1. A review of the facility's "Daily Schedule of Unit Activities" revealed that a "Nurses Group" was schedule daily at 9:45 a.m. and at 6:00 p.m. This group was not included on the MTPs for Patients A1, A2, A3, A4, A5, A6, A7 and A8.

2. During observation on 11/17/14 at 9:45 a.m., active sample patients A5, A6 and A7 were observed in the dayroom attending and participating in a "Nurses Group" conducted by RN2. The topic of the group was "Positive Thinking" and how positive thinking helps the patient's health. This group was not included on these patients' MTP.

Based on record review and interview, the facility failed to ensure that active treatment measures listed on the treatment plan and/or unit schedule were documented in the medical record to include the patients' attendance or non-attendance, specific topics discussed, and the patients' behavior during group, and their response to the group intervention, including level of participation, understanding, and specific comments. This included groups assigned to activity therapy staff, recovery specialists, and nurses for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8. This failure hindered the treatment team from 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.

Findings include:

A. Document Review

1. A review of the facility's "Daily Schedule of Unit Activities" listed the following groups scheduled to be held through out the day. "Nurses Group" conducted by the RN and/or LPN two times per day; "Current Events" conducted the Behavioral Technicians; "Activities Group" conducted by activity therapy staff, "Exercise" conducted by activity therapy staff and/or behavioral technicians, and "Psychoeducation" conducted by the recovery specialist two times per day. All patients were reportedly expected to attend these groups.

2. The master treatment plans for the following patients were reviewed (dates of plans in parentheses): A1 (11/11/15); A2 (11/1/15); A3 (11/7/15); A4 (11/15/15); A5 (11/8/15); A6 (11/3/15); A7 (10/12/15); and A8 (11/12/15). This review revealed the following findings:

3. Activity Therapy Group Treatment Notes:

a. Patient A1's group treatment notes documented the patient's attendance and non-attendance for the period of 11/11/15 through 11/16/15. This documentation showed that the patient attended Social skills building and interpersonal development one time during this period.

b. Patient A3's group treatment notes documented that the patient attended "interpersonal development, social skills building 11/9/15 through 11/14/15. This documentation showed that the patient only attended the "Social Skills Building" and "Yoga/Exercise" Groups one time during this period.

c. Patient A4's group treatment notes documented that the patient attended the social skills building group on 11/16/15. Although, there was more information regarding the patient's response during the group session, no information was provided regarding the specific topics discussed or game used during the group session.

d. Patient A5's group treatment notes documented that the patient attendance and non-attendance "interpersonal development, social skills building 11/8/15 through 11/14/15." This documentation showed that the patient only attended the "Interpersonal Development Group" one time during this period.

e. Patient A6's group treatment notes documented the patient's attendance and non-attendance in the "interpersonal development, social skills building, and yoga/exercise" groups for the period of 11/3/15 through 11/9/15. This documentation showed that the patient attended the interpersonal development and social Skills Building groups three times and attended the yoga/exercise" group one time during this period. For the period from 11/10/16 through 11/16/15, the patient attended the interpersonal skills and social skills building groups four times during this period and attended the yoga/exercise group two times during this period.

f. Patient A7's group treatment notes documented the patient's attendance and non-attendance in the "interpersonal development, social skills building, and yoga/exercise" groups for the period of 11/2/15 through 11/8/15. This documentation showed that the patient attended the interpersonal development three times, attended the social Skills Building group four times and attended the yoga/exercise group one time during this period. For the period from 11/9/16 through 11/15/15, the patient attended the interpersonal skills two times, attended the social skills building group three times, and attended the "yoga/exercise group" one time during this period.

g. Patient A8's group treatment notes documented the patient's attendance and non-attendance in the "interpersonal development, social skills building, and yoga/exercise" groups for the period of 11/12/15 through 11/16/15. This documentation showed that the patient attended the interpersonal development and social Skills Building groups three times and did not attended the "yoga/exercise group" during this period.

h. The group treatment notes entered in the facility's electronic medical records by activity therapy staff did not include sufficient information about the patient's response during group sessions. A review of the treatment notes in the electronic medical record revealed that there were no notes reflecting the specific topics discussed during the interpersonal development and social skills building group sessions. In addition, these treatment notes failed to consistently include the patient's level of participation, level of understanding, specific comments made by the patient, and behavior exhibited during group such as sleeping, walking in and out of group, etc. Additionally, there was no information provided regarding the patient's participation level in the exercise group sessions.

i. Treatment plans showed that "Motivational Enhancement Therapy" was assigned to activity therapy staff five times for 5 days for five (5) of eight (8) active sample patients (A1, A3, A5, A6 and A7). There was no documentation in the medical record reflecting whether patients attended or did not attend this group, topics discussed or patients' response to the group intervention.

j. There were no treatment notes showing Patient A2's attendance or non-attendance in groups conducted by activity staff.

4. Recovery Specialist Group Treatment Notes:

a. Patient A3's group treatment notes documented that the patient attended "Psychoeducation" Group on 11/9/15. The group topic was "Relapse Prevention." However, the only patient response noted was "Attentive" mood/affect. There were no notes regarding the patient's level of understand, behavior(s) exhibited during the group session. The comments section of the form noted, "Most consumers were attentive and participated openly." This was not an individualized statement related to Patient A3's responses to the group session.

b. Patient A6's group treatment notes documented that the patient attended both sessions of the "Psychoeducation" Group on 11/4/15- 11/6/15, on 11/6/15, 11/9/15 and 11/16/15. The specific group topics were consistently documented. However, the only patient response noted was "Attentive" and "Appropriate" mood/affect. There were no notes regarding the patient's level of understand, behavior(s) exhibited during the group session. During observation on 11/16/17 at approximately 10:50 a.m., Patient A6 was in the dayroom attending the group but was sitting with his/her head down and did not verbally participate in the group discussion. During interview on 11/18/15 at 10:30 a.m., Patient A6 was asked about his/her non-participation during group sessions. Patient A6 stated, "I just can't get myself into it." The patient stated that s/he was not happy about some information received during his/her court hearing.

c. Patient A7's group treatment notes documented that the patient attended both sessions of the "Psychoeducation" Group on 10/14/15 - 10/16/15, 10/19/15 - 10/20/15, 10/22/15 - 10/23/15, 10/26/15 - 10/29/15, 11/2/15, 11/4/15 and 11/16/15. The specific group topics were consistently documented. However, the only patient response noted was "Attentive" and "Appropriate" mood/affect. There were no notes regarding the patient's level of understand, behavior(s) exhibited during the group session.

d. Patient A8's group treatment notes documented that the patient attended "Psychoeducation" Group on 11/16/15. The group topic was "progressive stages of anger." However, the only patient response noted was "Attentive" and "Appropriate" mood/affect. There were no notes regarding the patient's level of understand, and behavior(s) exhibited during the group session.

e. Treatment plans showed that "Motivational Enhancement Therapy" was assigned to the recovery specialist five times a week for five days for three (3) of eight (8) active sample patients (A4, A5, and A6). There was no documentation in the medical record reflecting whether patients attended or did not attend this group, topics discussed or patients' response to the group intervention.

f. There were no treatment notes showing Patients A1's, A2's, A4's, and A5's attendance or non-attendance in the psychoeducation group conducted by the recovery specialist.

5. Nurses Group Treatment Notes:

A review of the "DAP [Data, Assessment, Plan]/Shift notes for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) revealed that there was no documentation by RNs or LPNs regarding patients' participation or lack of participation in the "Nurses Group" on listed on the "Unit Daily Schedule" and scheduled to be held daily at 9:45 a.m. and again at 6:00 p.m. There was no documented including the topic discussed and the patient's level of participation, level of understanding, specific comments made by each patient's, and behaviors observed during group sessions.

B. Staff Interviews and Observation

1. During observations on 11/17/15 at 9:50 a.m. on the Psychiatric Care Unit. Patients A5, A6, and A7 attended the "Nurses Group" listed on the "Daily Schedule of Unit Activities" and was conducted by RN2. During interview on 11/17/15 at 10:20 a.m., RN2 reported that this was the first time she had conducted the group and was not aware of the documentation requirements for groups.

2. In an interview on 11/17/15 at 10:35 a.m. with the Activities Director, group treatment notes were reviewed. She agreed that the group treatment notes were not as detailed and did not consistently contain information about the response to the group interventions. She acknowledged that the patient's response to the intervention did not include the patient's behaviors during group, level of understanding, and specific comments made about the intervention.

Based upon record and document review, direct observation, and interviews, the facility failed to:

I. Provide active treatment for seven (7) of eight (8) active sample patients (A1, A2, A3, A5, A6, A7 and A8). Specifically, therapeutic group modalities were often not held, poorly attended, and/or failed to provide treatment based upon a patient's individually assessed needs. This failure potentially resulted in care, which was generic as well as sub-optimal patient outcomes.

II. Appropriately evaluate and document episodes of restraint for one (1) of eight (8) active sample patients (A3) and 4 of 6 non- sample patients (R1, R4, R5 and R6) whose records were selected to review episodes of restraint. Specifically, none of the 5 patients had a documented one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements and facility policy. One patient (R5) sustained an injury serious enough to require transfer to a medical facility after an episode of restraint. In addition, there was no documentation provided by the facility of a subsequent revision of the MTP for Patient A3. These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to patients. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients.

Findings include:

I. Failure to provide active treatment

A. Record Review

1. Patient A1 was admitted to the facility on 11/11/15 with a diagnosis of "Bipolar I disorder, current or most recent episode unspecified." An Activity Therapy Summary Progress Note revealed that the patient attended only three (3) of 15 assigned groups in the 5-day interval since admission. Nursing progress notes did not document attendance or participation in any of the assigned Nursing group held during this same period, nor that any alternative therapeutic modality was offered to Patient A1. No documentation of attendance or participation in any Psycho-education group nor alternative therapies provided was present for this interval in the patient's medical record.

2. Patient A2 was admitted to the facility on 11/1/2015 with a diagnosis of "Schizoaffective disorder." An Activity Therapy Summary Progress Note revealed that the patient attended only 2 of 21 assigned Activities groups between 11/1/15 and 11/8/15. An Activity Therapy Summary Progress Note dated 11/10/2015 indicated that the patient was provided alternative activities but failed to specify what these modalities were, how they were related to the patient's assessed needs, or the outcomes of these interventions. Nursing Progress notes between the dates of 11/1/2015 and 11/15/2015 did not document attendance or participation in any of the daily Nursing groups, nor that any alternative therapeutic modality was offered to Patient A2. Documentation revealed two Psycho-education group refusals on 11/6/15. No documentation of attendance or participation in subsequent Psycho-education groups between 11/7/15 and 11/16/15 nor of alternative therapies provided was present in the patient's medical record.

3. Patient A3 was admitted to the facility on 11/8/15 with a diagnosis of "Disruptive Mood Disorder." An Activity Therapy Summary Progress Note revealed that the patient attended only 12 of 21 assigned Activities groups between 11/9/15 and 11/16/15. No alternative activities were documented in the medical record. Nursing progress notes between 11/9/15 and 11/16/15 did not document attendance or participation in any of the assigned Nursing Groups, nor that any alternative therapeutic modality was offered to patient A3. There was documentation of attendance at only one Psycho-education Group on 11/9/15. No documentation of attendance or participation in further Psycho-education groups nor of alternative therapies provided were present in the patient's Medical Record for the period from 11/9/15 to 11/15/15.

4. Patient A5 was admitted to the facility on 11/8/15 with a diagnosis of "Bipolar I disorder, current or most recent episode manic, with psychotic features." An Activity Therapy Summary Progress Note revealed that the patient attended only 1 of 18 assigned Activities groups between 11/8/15 and 11/14/15. No alternative activities offered to Patient A5 were documented in the patient's medical record. Nursing progress notes did not document any attendance or participation in any of the assigned Nursing Groups, nor that any alternative therapeutic modality was offered to A5 for this interval. Documentation revealed attendance at only two (2) of eight (8) assigned Psycho-education groups in the interval between 11/7/16 and 11/15/16. No alternative therapy offered to Patient A5 was documented in the patient ' s medical record.

5. Patient A6 was admitted to the facility on 11/3/15 with a diagnosis of "Schizoaffective disorder." An Activity Therapy Summary Progress Note revealed that the patient attended only 10 of 21 assigned Activity groups between 11/9/15 and 11/16/15. No alternative activities offered to Patient A6 were documented in the patient's medical record. Nursing progress notes did not document attendance or participation in any of the assigned Nursing Groups, nor that any alternative therapeutic modality was offered to A6. Documentation revealed attendance at only 2 of 9 assigned Psycho-education groups (both on 11/9/15) in the interval between 11/6/15 and 11/15/15. No alternative therapy offered to Patient A6 was documented in the medical record.

6. Patient A7 was admitted to the facility on 10/12/15 with a diagnosis of "Schizoaffective disorder." An Activity Therapy Summary Progress Note revealed that the patient attended only 6 of 21 assigned Activity Groups between 11/9/15 and 11/16/15. No alternative activities offered to patient A7 were documented in the patient's medical Record. Nursing progress notes did not document attendance or participation in any of the assigned Nursing Groups, nor that any alternative therapeutic modality was offered to A7. Documentation revealed attendance at only 2 of 11 assigned Psycho-education groups (both on 11/12/15) in the interval between 11/5/15 and 11/16/15. No alternative therapy offered to Patient A7 was documented in the patient's medical record.

7. Patient A8 was admitted to the facility on 11/12/15 with a diagnosis of "Bipolar I disorder, current or most recent episode unspecified." An Activity Therapy Summary Progress Note revealed that the patient attended only 6 of 12 assigned groups between 11/12/15 and 11/16/15. No alternative activities offered to Patient A8 were documented in the medical record. Nursing progress notes did not document attendance or participation in any of the assigned Nursing Groups, nor that any alternative therapeutic modality was offered to A8. Documentation revealed attendance at no assigned Psycho-education group between 11/12/15 and 11/15/15. No alternative therapy offered to Patient A8 was documented in the patient's medical record.

B. Staff Interview

In an interview on 11/16/15 at approximately 4:00 p.m. in the group room on PCU for male patients, the Rehabilitation Specialist indicated that she had been away from 11/9/15 through 11/16/15 for vacation and was uncertain as to whether Psycho-Education groups were run in her absence.

C. Direct Observations

1. Patient A1 did not receive active treatment during one (1) of three (3) observed intervals. On 11/16/15 between 3:30 p.m. and 3:55 p.m., patient A1 was scheduled to attend a Psycho-Education group for Anger Management. S/he initially was not present but was sitting alone watching television in the PCU day room. When asked why s/he was not attending s/he stated, "I have a headache." After discussion with the surveyor s/he did agree to join the group and attended the last 10 minutes. S/he said no other staff had prompted him/her to attend prior to my inquiry. The group consisted of three (3) out of nine (9) patients who were assigned this modality. As patient A1 entered another patient exited. Three patients not in attendance were sleeping and three others were wandering the unit during this 30-minute therapeutic modality.

2. Patient A2 did not receive active treatment during one (1) of three (3) observed intervals. Patient A2 was assigned the Psycho-Education group titled Anger Management, which was scheduled at 11/16/15 between 3:30 p.m. - 3:55 p.m. Patient A2 slept in his/her room during this interval and no staff were observed prompting patient A2 to attend this therapeutic modality.

3. Patient A3 did not receive active treatment for 2 of 3 sampled observations. Patient A3 was observed on 11/16/15 in the Geriatric PCU day room between 2:45 p.m. and 3:15 p.m. when a Psycho-Education group (which was supposed to start at 2:30 p.m.) was taking place. Six (6) patients were present however, four (4) sat on the periphery (including patient A3) and did not engage in the therapeutic modality. Two (2) patients were at a center table interacting with the Rehabilitation Specialist. No staff made any attempts to engage the remaining four (4) patients. Staff came and left with loud distraction throughout this group and the television remained on. Additionally the two (2) patients who had engaged were distracted when a staff member came to wipe down the top of the table where they were seated. The group leader made no attempt to limit this distraction. When asked what the curriculum for this group was supposed to have been, the Rehabilitation Specialist stated that she had been away and was not aware of the treatment plans for the patients on the Geriatric PCU. She further noted that attempting to engage these patients was often difficult and so she would speak to whatever topic created the most interested for those present: "Sometimes I just tell stories." On 11/17/15 again in the day room of the Geriatric PCU a Psycho-education titled "Self Esteem Bingo" was scheduled to begin at 2:30 p.m. At 2:50 p.m., the group leader arrived. Of six (6) patients, three (3) initially engaged including patient A3 however s/he quickly lost interest and participated only minimally from that point.

4. Patient A4 did not receive active treatment for two (2) of three (3) sampled observations. Patient A4 was assigned to attend the Psycho-Education group on 11/16/215 in the Geriatric PCU. The group was scheduled to start at 2:30 p.m., however the group leader did not arrive until 2:45 p.m. Patient A4 remained in the periphery alternately sleeping and watching television. The group leader spent her time with two (2) patients at a center table and made no observable attempt to engage patient A4 in the therapeutic modality. On 11/17/15 patient A4 was assigned to another Psycho-education group titled "Self Esteem Bingo" which was scheduled to begin at 2:30 p.m. The group leader arrived at 2:50 p.m. Patient A4 remained in his/her chair on the periphery of the group and did not participate in the assigned modality.

II. Failure to appropriately document after the initiation of restraint

A. Record and Document Review - Progress notes, incident reports, and the "Mechanical/Chemical Restraint Order Sheet" provided by the facility for selected incidents of seclusion and restraint were reviewed for adherence to facility policy and CMS guidelines. The documentation of information pertinent to these episodes of restraint was chaotic, with some information contained in incident reports, some found in the "Mechanical/Chemical". Restraint Order Sheet," and other data noted in nursing progress notes. Therefore, there was no comprehensive record containing a linear and organized account of the patient's response to these interventions nor a detailed assessment of an individual's medical needs as required by CMS guidelines and facility policy.

1. Patient A3 experienced an episode of agitation at 5:04 p.m. on 11/9/15 per an entry in the nursing progress note. A telephone order was obtained at 5:04 p.m. by the nurse for an IM of Zyprexa 10mg, which required a therapeutic hold to administer. The Mechanical/Chemical Restraint Order Sheet indicated that a manual hold was required to administer Zyprexa 10 mg IM due to behavior of agitation. This order sheet was not cosigned by the attending psychiatrist until 11/17/15 at 12:00 p.m. A nursing progress note dated 11/9/15 at 5:04 p.m. indicated that the patient "walked/paced the unit in an agitated manor verbally assaulting peers and staff members with threats of harm if he wasn't released by 5:30 p.m." The assessment included: "intrusive to nursing station, verbally assaultive, aggressive with staff and peers, increased agitation and increased anger." "Plan was to notify Psych MD, notify nursing supervisor." This note was signed by "RN4" with no other identification of this staff member. There was no documentation regarding the effectiveness of the intervention, complications, or pertinent observations which might be helpful in case a similar intervention was needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS.

2. Patient R1 on 11/8/15 at 10:30 p.m. became agitated "throw(ing) a stool at staff, refusing to leave shower stall, screaming and slapping" as documented on the Mechanical/Chemical Restraint Order Sheet. S/he was place in prone restraint and an order for Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg IM was obtained from the psychiatrist. Though the LPN's progress note indicated this intervention was effective there was no documentation regarding complications or pertinent observations that might be helpful should a similar intervention be needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS.

3. Per the "Mechanical/Chemical Restraint Order Sheet," Patient R4 on 10/15/15 at 1:00 p.m. was observed to be displaying physical aggression by attacking staff as well as verbally threatening to break glass after climbing the windowsills. A telephone order for prone restraint as well IM medication was obtained from a psychiatrist at this time (a psychiatrist signature appears in the designated line on The Mechanical/Chemical Restraint Order Sheet, however this signature was neither dated nor timed as of 11/16/15). A nursing progress note described the behaviors prompting this intervention, however there was no documentation regarding the effectiveness of the intervention, complications, or pertinent observations which might be helpful in should a similar intervention be needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS. On 10/16/15 at 1:45 a.m., as documented in a nursing progress note, Patient R4 again became agitated and attempted to wrap a blanket around his/her neck. An order for prone restraint and Zyprexa 20mg IM was obtained by the RN (a psychiatrist signature appears in the designated line on the "Mechanical/Chemical Restraint Order Sheet," however this signature was not dated or timed as of 11/16/15). There was no documentation regarding the effectiveness of the intervention, complications, or pertinent observation that might be helpful should a similar intervention be needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS.

4. Patient R5 on 9/06/15 at 9:00 p.m. was placed in a therapeutic hold by Leesburg Police Department who had been called by "[Staff's first name]. LPN "due to the patient's escalating behavior as documented in an incident report completed on 9/6/15 at 11:00 p.m. A telephone order was obtained from the psychiatrist for administration of Geodon 20mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM. Incident report documentation subsequently reflected: "Soon after it was noted that (patient's) right ankle was swelling and turning black and blue, (the patient) had an abrasion on (his/her) left knee and swelling above one of (his/her) eyes. EMS was called and (the patient) was taken to LRMC for medical clearance." On 9/06/15 at 10:15 p.m. the same patient was placed in prone restraint after "hitting windows @ nurse's station, stating (he/she) would stab one of us with a pencil after stating [Staff's first name] was a snitch." The RN obtained a telephone order from the physician for prone restraint printing the physician's name on the line where the physician's signature was to be entered on the Mechanical/Chemical Restraint Order Sheet. (This physician had not counter signed the order as of 11/16/15). There was no documentation regarding the effectiveness of the intervention, complications, or pertinent observations that might be helpful should a similar intervention be needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS.

5. Patient R6 on 8/23/15 at 8:15 p.m. was noted in an incident report to have been "agitated all evening" and chased the behavioral technician who had approached him/her with a snack. "Consumer was severely agitated and became a (sic) iminent (sic) danger to staff. TEAM approach while MD was called to get order for ETOH (sic)." A telephone order was received for a therapeutic hold as well as administration of Zyprexa 20mg IM and Benadryl 50mg IM. The Mechanical/Chemical Restraint Order Sheet for this intervention was still not signed by the psychiatrist as of 11/16/15. There was no documentation regarding the effectiveness of the intervention, complications, or pertinent observations that might be helpful should a similar intervention be needed in the future (as per hospital policy), nor was there an assessment of the patient's reaction to the intervention and medical condition from a physician or specially trained registered nurse as required by CMS.

B. Policy Review

1. The facility failed to follow its own policy regarding use of restraint procedures. The facility's policy titled: "Special Treatment Procedures-Restraints" indicated, "Face to face assessment must be done within four (4) hours of the initiation of restraints for individual 18 years of age or older and within two (2) hours for younger individuals." The policy further stated, "The authorized practitioner conducts face-to-face assessment with individual within one (1) hour." At time of assessment the authorized practitioner signs the telephone/verbal order and:

a. Reviews the restraint process and documentation of events.

b. Documents a clinical interpretation including; effectiveness (sic) of restraint, individual response to procedure and any adverse consequences related to restraint as well as any significance to current treatment plans in progress note.

c. Sign on Seclusion and Restraint Record (PH:059) that review was done."

2. On 11/17/15, the Director of Medical Records delivered a policy titled: "ETO (Emergency Treatment Order) Revised Protocols." The policy stated: "Current Mandated Protocols now include that Emergency Treatment Orders now have the same requirement of Seclusion and Restraint in regard to documentation and clinical justification of orders."

C. Staff Interview

On 11/18/15 at 12:15 the Medical Records Director and Hospital Administrator in the presence of the agency Quality Improvement Director acknowledged that the facility was not performing one hour face to face assessments for patients requiring manual holds, stating they had failed to recognize that this modality constituted an episode of restraint. They agreed the facility was not following their own policy regarding documentation nor CMS guidelines for review of seclusion and restraint. They further acknowledged that the facility had no training curriculum for nurses who were conducting one hour face to face evaluations for patients who had experienced an episode of restraint. They further acknowledged that the nurses who had performed the one hour face to face evaluation for patients A3, R1, R4, R5 and R6 had no special training to perform this duty and that documentation of these episodes was not consistent with hospital or CMS requirements.

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

I. Ensure that the Clinical Director monitor and evaluate the quality and effectiveness of the treatment program to assure that patients receive the intensity and quality of care appropriate to their needs. (Refer to B144)

II. Ensure adequate clinical leadership in nursing to monitor the quality of psychiatric nursing care and provide supervision of nursing staff. (Refer to B147 and B148)

III. Ensure sufficient numbers of registered nurses to staff two high acuity Adult Psychiatric Units and one Geriatric Unit. Specifically, the facility failed to consistently assign a RN to cover these units. Frequently only Licensed Practical Nurses (LPNs) covered these units with only a nurse supervisor and RN Lead who were assigned to cover the entire facility, which included five units and the admission/intake area. This practice results in the lack of ongoing active treatment interventions and psychiatric nursing care provided by registered nurses. In addition, this deficit practice potentially leads to an unsafe patient environment because of the lack of an immediate present of a registered nurse to provide ongoing direction and supervision to paraprofessional nursing staff (LPNs and Behavioral Technicians) in the provision of nursing care. (Refer to B150)

Based upon observation, record review, and interview, the Medical Director failed to monitor and evaluate the quality and effectiveness of the treatment program to assure that patients receive the intensity and quality of care appropriate to their needs. Specifically, the Medical Director failed to:

I. Ensure that Master Treatment Plans (MTPs) were revised when patients were placed in restraint (manual hold). Specifically, for one (1) of eight (8) active sample patients (A3), the MTP was not revised to reflect problem statements related to the use of restraint to control aggressive behavior, treatment goals, and active treatment interventions outlining healthy alternatives and approaches for the patient to use to replace aggressive behavior(s). This failure impedes the provision of active treatment to meet the specific treatment needs of patients. (Refer to B118)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the MTPs did not include: (1) Behaviorally descriptive psychiatric problem statements based on how each patient manifested presenting symptoms. (Refer to B119)

(2) Observable and measurable short-term goals written in behavioral terms. (Refer to B121)

(3) Specific individualized active treatment interventions. (Refer to B122)
Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that active treatment groups was provided for seven (7) of eight (8) (A1, A2, A3, A5, A6, A7 and A8) sample patients. Specifically, therapeutic group modalities were often not held, poorly attended, and/or failed to provide treatment based upon a patient's individually assessed needs. This failure potentially resulted in care, which was generic as well as sub-optimal patient outcomes. (Refer to B125-I)

IV. Ensure appropriate evaluate and document episodes of restraint for one (1) of eight (8) active sample patients (A3) and 6 of 4 non-sample patients (R1, R4, R5 and R6) whose records were selected to review episodes of seclusion and restraint. Specifically, none of the 5 patients had a documented one-hour face-to-face assessment by a physician or specially trained registered nurse within one hour as scripted by CMS requirements and facility policy. One non-sample patient (R5) sustained an injury serious enough to require transfer to a medical facility after an episode of restraint. In addition, there was no documentation provided by the facility of a subsequent revision of the MTP for patient A3. These deficiencies result in inadequate oversight of a potentially harmful procedure and fail to reduce risk of further reoccurrence of subsequent harm to the patient. Additionally, these failures result in a restriction of the patient's rights without adequate documented justification and demonstrate unsafe practices that can result in serious outcomes for patients. (Refer to B125-II)

Based on document review and staff interview, the facility failed to have a Director of Nursing (DON). There was no registered nurse (RN) with a Master's Degree in Psychiatric Mental Health nursing or a RN who received supervision from a registered nurse with a Master's Degree in Psychiatric Mental Health Nurse designated to provide oversight and monitor the quality of nursing care provided by nursing personnel. Instead, the nurse supervisor on duty along with the hospital administrator was reportedly responsible for the duties associated with the DON position.

Findings include:

A. Interview

1. During the entrance contact on 11/16/17 at approximately 9:30 a.m., the Hospital Administrator reported that the Director of Nursing position was vacant and that an interim DON had not been identified. He stated that he and nursing supervisors were responsible for the duties of the DON.

2. In an interview, a nursing supervisor stated that she was not responsible for performing the duties of the Director of Nursing or acting as the DON and stated, "To my knowledge, no one has been assigned to act as the DON."

B. Document Review

The facility's policy titled, "Designee in Absence of Director of Nursing" revised February 2015 and signed 4/27/15, stipulated that, "To ensure the proper supervisor of Nursing, in the absence of the Director of Nursing, a nurse shall be designated and authorized to act in her absence. The Hospital Administrator is back-up. A Nursing Supervisor will be responsible for the nursing services in the absence of the Director of Nursing. Each Program Supervisor is responsible for designating a nursing person to be in charge at all times." The facility was in violation of its own policy to designate "a Nursing Supervisor" to be responsible for nursing services in the absence of the Director of Nursing.

Based on observation, record review, and interview, the facility failed to have a Director of Nursing (DON) to provide adequate oversight to ensure quality nursing services. Specifically, the facility failed to designate a DON who was responsible to monitor to:

I. Provide eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) with Master Treatment Plans (MTPs) that included individualized nursing treatment interventions that stated specific treatment modalities with a focus of treatment based on each patient's presenting problems and goals. Specifically, MTPs: (a) included routine nursing functions selected from options on the facility's electronic medical record. These options stated as treatment interventions were generic, vague, and global statements without an identified method of delivery; (b) included no RN interventions for five (5) of eight (8) active sample patients (A2, A4, A6, A7 and A8), and (3) failed to include a "Nurse Group" on the treatment plan that was listed on the daily unit schedule and attended by three (3) of eight (8) active sample patients (A5, A6, and A7). These deficiencies result in a failure to guide nursing staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective active treatment.

Findings include:

I. Failure to include individualized nursing treatment intervention

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (11/11/15); A2 (11/1/15); A3 (11/7/15); A4 (11/15/15); A5 (11/8/15); A6 (11/3/15); A7 (10/12/15); and A8 (11/12/15). This review revealed that the MTPs included but not limited to the following routine and generic statements (such as evaluating, administering medications, monitoring, and encouraging) and/or other generic nursing functions written as treatment interventions to be delivered by registered nurses (RN) and other nursing staff. Several intervention statements were identical or similarly worded.

1. Patient A1 had the following generic and/or routine nursing function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/12/15 documented that, "[Patient's name] reports depressive and panic attacks. [S/he] reports [s/he] has fear of his living environment due to an attack last October that occurred in [his/her] front yard...[S/he] asserts 'A 52 year old [gender] should be able to have a conversation without crying'...[S/he] reports nightmares about [his/her] attack in October 2014." The intervention identified for the following problem included:

Problem #1 - "Ineffective coping."

RN Intervention: "Encourage individual to discuss current life situations."

The RN intervention above was a routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. This intervention statement failed to include whether the intervention would be delivered in individual or group sessions.

2. Patient A2 had no interventions related psychiatric problems identified to be implemented by the registered nurse or other nursing staff.

3. Patient A3 had the following identical generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/8/15 documented that, "...physically abusive towards [his/her] [spouse]...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..." The interventions identified for the following problems included:

a. Problem # 1: "Bullying or threatening behaviors."

LPN Intervention: "Medication/Consults/Referrals: Outpatient therapy for medication management/problem solving."

b. Problem #2: "Violence risk: directed towards other."

RN Intervention: "Medications/Consults/Referrals."

The nursing interventions above were routine staff functions and not specific patient outcome statements related to the patient's improvement. There was no active treatment intervention regarding the RN and LPN assisting and teaching the patient non-harmful ways of dealing with aggressive behavior. In addition, there was no active treatment intervention regarding he RN and LPN assisting the patient to understand prescribed medications including the benefits of medication and need to continue medications after discharge. None of the intervention statements included a method of delivery (individual or groups sessions).

4. Patient A4 had the following generic and/or routine nursing function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/16/15 documented that, "...physically abusive towards [his/her] [spouse]...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..." The intervention identified for the following problem included:

Problem # 1: "Violence risk: directed towards others."

LPN Intervention: "Monitor behavior of violence towards other as it occurs."

There were no interventions related to this psychiatric problem identified to be implemented by the registered nurse.

The nursing intervention above was a routine staff functions and not a specific patient outcome statement related to the patient's improvement. There was no active treatment intervention regarding the RN and/or LPN assisting and teaching the patient non-harmful ways of dealing with aggressive behavior. The intervention statement failed to include a method of delivery (individual or groups sessions).

5. Patient A5 had the following generic and/or routine discipline function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/9/15 documented that, "...[Patient's name] has threatened to shoot [him/herself] and is violent toward others. [Patient's name] was also observed to throw objects at family members...[Family member's name] reports that [Patient's name] used many drugs but [his/her] drug of choice seems to be crack cocaine...[Patient's name] has expressed visual hallucination as well as stating [s/he] sees bugs crawling on the walls and seeing people who are not there..." The intervention identified for the following problem included:

a. Problem # 1: "Substance abuse/chemical dependency."

RN Intervention: "Urge the patient to accept personal responsibility for substance abuse and consequent erratic behavior." Although there was no staff responsibility identified, the Lead Recovery Specialist stated that this was a nursing intervention, during an interview on 11/17/15 at 1:40 p.m.

The nursing intervention above was a routine staff functions and not a specific patient outcome statement related to the patient's improvement. There was no specific active treatment intervention reflecting information the RN would provide regarding substance abuse based on presenting symptoms and needs. The intervention statement failed to include a method of delivery (individual or groups sessions).

6. Patient A6 had the following generic and/or routine discipline function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/4/15 documented that, "...presumptive positive for Benzodiazepine...Client reported [s/he] took [his/her] mother medications, [s/he] states, 'I took 4 Xanax and 2 Vicodin' unknown dosages...[S/he] reports [s/he] is hearing a voice telling [him/her] to take [his/her] mother's medications and kill [him/herself]...Client reports multiple suicidal attempts in the past. [S/he] reports taking 175 multiple pills which lead to [him/her] being hospitalized..." The nursing intervention identified for the following problem included:

b. Problem #2: "Medication management."

LPN Intervention: "Monitor the clients use of expected benefit of the medications."

The patient also had problem statements related to "Non-compliance with medical or other recommended treatments..." and "Depressed Mood" There was no interventions related to any of these psychiatric problems identified to be implemented by the registered nurse.

The nursing intervention above was a routine nursing functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to understand prescribed medications including the benefits of medication and need to continue medications after discharge. The intervention statement did not include a method of delivery (individual or groups sessions).

7. Patient A7 had the following generic and/or routine nursing function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 10/13/15 documented the following descriptive information: "...[Patient's name] is fixated on paranoid thoughts that others, including [his/her] son, are stealing [his/her] money...reports that this boyfriend has been stealing [his/her] medications and [his/her] Cogentin is missing completely...reports that [s/he] missed [his/her] last Invega injection that was due 10/6/15..." The intervention identified for the following problem included:

a. Problem #1: "Medication management."

LPN Intervention: "Monitor the clients use of expected benefit of the medications."

The patient also had a problem statement related to "Agitated behavior..." There were no interventions related to any of the psychiatric problems identified to be implemented by the registered nurse.

The nursing intervention above was a routine nursing function and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to understand prescribed medications including the benefits of medication and need to continue medications after discharge.

8. Patient A8 had the following generic and/or routine nursing functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/12/15 documented that, "...Paperwork accompanying individual from the hospital reports that [s/he] took 10-15 pills of 500 mg. penicillin because [s/he] felt like [his/her] family did not want [him/her] to live there...[his/her] mother told nurse that [Patient's name] attempted to kill [him/herself] with a knife 2 days ago...[S/he] reports severe issues with housing and moderate issues with employment,..." The interventions identified for the following problems included:

a. Problem #1: "Violence risk: directed towards self."

LPN Intervention: "Maintain and convey a calm attitude."

b. Problem #2: "Ineffective coping."

LPN Intervention: "Encourage individual to discuss current life situations."

The patient also had problem statements related to "Speech, behavior, or reports indicating significant danger to self." There were no interventions related to any of the psychiatric problems identified to be implemented by the registered nurse.

The nursing interventions above were routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. There was no active treatment intervention regarding the RN and LPN assisting the patient to deal with suicidal thoughts and behaviors. In addition, there was no active treatment intervention regarding the RN and LPN assisting the patient to identify and use healthier coping strategies when feeling suicidal. None of the intervention statements included a method of delivery (individual or groups sessions).

B. Staff Interview

In an interview on 11/17/15 at 10:20 a.m., RN4 acknowledged that nursing interventions were not individualized and were routine nursing functions that would be provide to any patient regardless of presenting symptoms.

II. Ensure that active treatment measures listed on the treatment plan and/or program schedules were documented in the medical record for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, there were no treatment notes reflecting the attendance or non-attendance in the nurse led group. This failure hindered the treatment team from determining the patient's response to nursing 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)

III. Ensure sufficient numbers of registered nurses to staff two high acuity Adult Psychiatric Units and one Geriatric Unit. Specifically, the facility failed to consistently assign a RN to cover these units. Frequently only Licensed Practical Nurses (LPNs) covered these units with only a nurse supervisor and RN Lead who were assigned to cover the entire facility, which included five units and the admission/intake area. This practice results in the lack of ongoing active treatment interventions and psychiatric nursing care provided by registered nurses. In addition, this deficit practice potentially leads to an unsafe patient environment because of the lack of an immediate present of a registered nurse to provide ongoing direction and supervision to paraprofessional nursing staff (LPNs and Behavioral Technicians) in the provision of nursing care. (Refer to B150)

Based on record review, observation, and interview, the facility failed to staff sufficient numbers of Registered Nurses (RNs) based on the numbers and acuity needs of patients on two high acuity Adult Psychiatric Units and one Geriatric Unit. Specifically, the facility failed to consistently assign a registered nurse (RN) to cover these units. Frequently only Licensed Practical Nurses (LPNs) covered these units with only a RN supervisor and RN Lead who were assigned to cover the entire facility, which included five units and the admission/intake area. This practice results in the lack of ongoing active treatment interventions and psychiatric nursing care provided by registered nurses. In addition, this deficit practice potentially leads to an unsafe patient environment because of the lack of an immediate present of a registered nurse to provide ongoing direction and supervision to paraprofessional nursing staff (LPNs and Behavioral Technicians) in the provision of nursing care.

Findings include:

A. Document Review

1. Psychiatric Care Unit (PCU) - Female: An analysis of the staffing data collected during the survey (11/16/15 and 11/8/15 through 11/14/15 revealed that the census on the Psychiatric Care Unit for female patients ranged from 12- 22 patients per day. There was no RN assigned to be physically present to cover for 14 out of 21 shifts and was consistently staffed with non-professional staff which included 1 or 2 LPNs and 2 or 3 Behavior Technicians. Therefore, a RN was not immediately available to provide ongoing interactions with patients to provide formal and informal active treatment interventions. Because a RN was not consistently available to provide immediate and ongoing interactions with patients and provide nursing care, there could be no documented progress and treatment notes reflecting patients' progress or lack of progress and response to active treatment interventions based on the RN's ongoing direct contacts, interactions, and observations of patients.

2. A review of the needs assessment document for the Psychiatric Care Unit for female patients revealed a very high patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, and clinical supervision of paraprofessional staff. The Needs Assessment Document completed on the first day of the survey revealed a census of fifteen (15) patients with the following needs:

a. Physical care needs: Two (2) patients requiring diabetic checks, four (4) patients on seizure precautions, and one (1) patient on a detoxification protocol.

b. Psychiatric nursing care needs: Four (4) patients potentially assaultive, one (1) patient actively assaultive, three (3) patients were considered a low suicidal risk, five (5) patients were on assault precaution, and two (2) patients were on fall precautions and four (4) patients constantly demanded staff time. In addition, the Psychiatric Care Unit for female patients reported that the average number of admission per week was seven (7) on the day shifts, eight (8) on the evening shift, and three (3) on the night shift. The average number of discharges per week was five (5) on the day shift, six (6) on the evening shift, and one (1) on the night shift.

3. Psychiatric Care Unit (PCU) - Male: An analysis of the staffing data collected during the survey (11/16/15 and 11/8/15 through 11/14/15 revealed that the census on the Psychiatric Care Unit for male patients ranged from 16 to 23 patients per day. There was no RN assigned to cover this unit 15 out of 21 shifts and was consistently staffed with paraprofessional staff which included 1 or 2 LPNs and 2 or 3 Behavior Technicians.

4. A review of the needs assessment document for the Psychiatric Care Unit for male patients revealed a high patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, and provide ongoing clinical supervision of paraprofessional staff (LPNs and Behavioral Technicians). The Needs Assessment Document completed on the first day of the survey revealed a census of seventeen (17) patients with the following needs:

a. Physical care needs: Three (3) patients on seizure precautions and two (2) patients on a detoxification protocol.

b. Psychiatric nursing care needs: Four (4) patients were potentially assaultive, three (3) patient were a low suicidal risk, one (1) patient was experiencing active hallucinations/delusions and was in potential jeopardy due to these symptoms, three (3) patients were on assault precaution, and one (1) patient was on fall precautions, and one (1) patient was under constant line of sight supervisions. In addition, the Psychiatric Care Unit for male patients reported that the average number of admission per week was six (6) on the day shifts, fourteen (14) on the evening shift, and two (2) on the night shift. The average number of discharges per week was eight (8) on the day shift, twelve (12) on the evening shift, and one (1) on the night shift.

5. Geriatric Unit: An analysis of the staffing data collected during the survey (11/16/15 and 11/8/15 through 11/14/15 revealed that the census on the Geriatric Unit ranged from six (6) to eight (8) patients per day. There was no RN assigned to cover this unit 17 out of 21 shifts and was consistently staffed with paraprofessional staff which included 1 LPN and 1 Behavior Technician.

6. A review of the needs assessment document for the Geriatric Unit revealed a patient acuity that would require immediate, consistent, and ongoing oversight by a registered nurse. The patient acuity on this unit required a registered nurse to be available to provide active treatment interventions, complete nursing assessments, document patient treatment and progress, and provide ongoing clinical supervision of paraprofessional staff (LPNs and Behavioral Technicians). The Needs Assessment Document completed on the first day of the survey revealed a census of seven (7) patients with the following needs:

a. Physical care needs: One (1) patient requiring partial assistance with bathing, feeding, hygiene, etc., one (1) requiring assistance with mobility, two (2) patients on diabetic checks, seven (7) patients requiring range of motion exercises, and one (1) patient requiring skin care.

b. Psychiatric nursing care needs: Seven (7) patients potentially assaultive, three (3) patients were actively assaultive, two (2) were a low suicidal risk, four (4) patients were experiencing active hallucinations/delusions and were in potential jeopardy due to these symptoms, seven (7) patients were on assault precaution, one patient (1) was on elopement precautions, five (5) patients were on fall precautions, and two (2) patients were under constant line of sight supervisions. In addition, the Geriatric Unit reported that the average number of admission per week was two (2) on the day shifts, two (2) on the evening shift, and one (1) on the night shift. The average number of discharges per week was two (2) on the day shift and three (3) on the evening shift.

7. The facility reportedly always scheduled one registered to serve as the nursing supervisor and one registered to be lead RN. These RNs were assigned to cover all five units in the facility. Therefore, these registered nurses were not immediately and consistently available to provide active treatment interventions and supervise care provided by paraprofessional staff (LPN and Behavioral Technicians). A review of the "Inpatient Services Staffing Sheets" revealed that there was no Lead RN assigned at all to cover the five units and admission area in the facility on the following dates: On 11/9/15 on the evening shift; 11/10/15 on the evening and night shifts; 11/11/15 on the day, evening and night shifts. [On the night of 11/11/15, there was only one RN available to cover the facility with only LPNs covering the five units]. There was also no Lead RN assigned on 11/15/15 for the evening and night shifts.

8. The review of the facility's FTE data revealed that there was a high RN vacancy rate. The facility reported 14 direct care RNs positions were allocated to cover the facility. The FTE data showed that in addition to a vacant Director of Nursing position, there were seven (7) direct care RN vacancies. The facility used agency RNs and overtime RNs to cover for shortages and call outs.

B. Unit Observations

1. During observation on the Psychiatric Care Unit for female patients on 11/16/15 at 10:20 a.m., the "Unit Daily Schedule" was reviewed. The surveyor asked about the "Nurses Group" on the schedule to be held from 9:45 to 10:15 a.m. There were two agency RNs on the unit and no regular employed RN or LPN was assigned. When asked which one of them conducted the group, RN1 stated, "We haven't done the group yet. We will do it later." The surveyor asked for a copy of the staff assignment sheet. RN1 stated she was not aware of a staff assignment sheet. RN4 arrived on the unit at approximately 10:30 a.m. and stated that there was a staff assignment sheet used by the facility and provided a copy of the form. She acknowledged that this sheet should be completed. The use of agency RN with no regularly employed licensed staff (RNs or LPNs) potentially results in the RN not having the support needed to augment their knowledge of the facility's protocols and individual patient issues on their assigned units.

2. During observation on the Psychiatric Care Unit for female patients at 10:30 on 11/16/15, an exercise group was scheduled. The Director of Medical Record, reminded the Behavioral Technician to do the exercise group. This group was held in the Dayroom with nine (9) patients. Only four (4) of the nine (9) patients participated in the chair exercises. Active sample patient A8 did not participate and the other four patients were sitting with their eyes closed or did not participate. These patients were not encouraged to participate.

3. During observation on the Psychiatric Care Unit for female patients at 9:45 a.m. on 11/17/15, the "Nurses Group" was conducted by an agency RN. A total of 13 patients were in attendance and patients not participating were encouraged to participate by RN2.

4. During observation on the Geriatric Unit on 11/17/18 from 1:00 p.m. - 1:30 p.m., there was no licensed nurse (RN or LPN) on the unit to provide nursing care and supervision of staff. There were two behavioral technicians and an activity assistant on the unit with 7 geriatric patients. During interview with both technicians, they stated that the LPN had gone for her lunch break at around 12:55 p.m. During a discussion at approximately 1:15 p.m. the Director of Medical Records when informed that there was no licensed staff (RN or LPN) on the unit stated, "This is allowed. We are only required to have two staff on the unit at all times." During interview with LPN 2 on 11/17/15 at approximately 1:35 p.m., she acknowledged that she was on break. When asked how breaks were cover, RN4 who had arrived on the unit stated, "Usually the float will come to cover."

C. Policy Review

1. A review of the facility's policy titled "Staffing - Adult" stipulated that, "There shall be a Registered Nurse on duty at all times, who is assigned responsibility for all nursing activities in the Hospital...For PCU [Psychiatric Care Unit], minimum staff shall consist of two nurses and two behavioral technicians...The sub-units of the psychiatric hospital, Geriatric and ACSU shall consist of a minimum of one nurse and one behavioral technician. This policy did not require a Registered nurse for each unit and used RNs and LPNs interchangeably to cover units.

2. The facility's policy titled, "Assignment of Staff," revised July 2013 and signed 7/13/13, stipulated that, "Each staff employee shall be under the supervision of a qualified RN. The Lead RN/LPN of the unit is responsible for the supervision of individual care activities within the unit. The Supervisor and Lead RN/LPN shall assess the unit needs and make assignments...and may include, specific individual care of all individuals on the unit...Special care needs...Meal and break times...Individual group/educational activities..." There was no written staff assignment completed on 11/16/15 on the Psychiatric Care Unit for female patients.

D. Staff Interviews

1. During interview on 11/17/15 at 10:20 a.m., RN2 reported that she was an agency RN and only worked one or two times a week. She had conducted the group and admitted that this was the first time she had done the group and was not aware of the documentation requirements for this group.

2. During interview on 11/17/15 at approximately 2:00 p.m., with RN4, the staffing pattern for period from 11/8/15 through 11/14/15 was reviewed. RN4 confirmed the high patient acuity on the two (2) Psychiatric Care Unit and one (1) Geriatric unit. She acknowledged the staffing showing that LPNs were assigned to cover without a RN consistent presence on the unit. She stated that there was always a nursing supervisors and Lead RN available to assist if needed.

3. During interview on 11/18/15 at 10:10 a.m., with RN1, the staffing was discussed. She acknowledged that a RN lead might not always be available primarily due to call outs. When asked about nursing assessment, she reported that occasionally the LPN completes the nursing assessment but it requires a RN signature.

III. Medical Record Review

1. A review of the shift notes for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) revealed no documentation by RNs regarding patients' participation or lack of participation in the "Nurses Group" on the "Unit Daily Schedule" scheduled daily at 9:45 a.m. and at 6:00 p.m. (Refer To B124)

2. A review of the Nursing Assessments for three (3) of eight (8) active sample patients (A3, A4, and A8) revealed that a LPN completed the nursing assessments and showed no immediate review and co-signature by a RN. The facility's policy titled "Nursing Admission" stipulated that, "The Nursing Assessment shall be completed by a licensed nurse with twelve (12) hours of admission. If the assessment is completed by a Licensed Practical Nurse, then the assessment must be reviewed and signed by a Registered Nurses within twenty-four (24) hours."

a. Patient A3's Nursing Assessment was completed by a LPN on 11/7/15. There was no RN signature on the form until 11/10/15. This was in violation of the facility's policy that required a signature by a RN within 24 hours.

b. Patient A4's Nursing Assessment was completed by a LPN on 11/15/15. There was no RN signature (electronic or handwritten) on the form at all.

c. Patient A8's Nursing Assessment was completed by a LPN on 11/12/15. There was no electronic signature. The handwritten RN signature was illegible and the date of the signature was missing. The form required a RN signature but did have a statement attesting that the assessment had been reviewed.

Based on record review and interviews, the Director of Social Work failed to monitor and evaluate the appropriateness of social services. Specifically:

I. Psychosocial assessments were incomplete and none provided a summary of findings, the anticipated social work role in treatment and discharge planning, nor described areas of special risk or concern for the patient. This failure to comprehensively assess the patient's psychosocial needs potentially resulted in suboptimal inpatient progress and/or inadequate discharge care plans. (Refer to B108)

II. Social work interventions on the Master Treatment Plans for six (6) of eight (8) active sample patients (A2, A3, A5, A6, A7 and A8) were not individualized to meet specific patient needs. Several social work interventions were generic and routine social work functions regardless of the different patients' problems and needs. There were no social worker interventions identified for two (2) of eight (8) active sample patients (A1 and A4). This deficiency potentially hampers the quality and appropriateness of the social services delivered to patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (11/11/15); A2 (11/1/15); A3 (11/7/15); A4 (11/15/15); A5 (11/8/15); A6 (11/3/15); A7 (10/12/15); and A8 (11/12/15). This review revealed that the MTPs included but not limited to the following routine and generic statements (such as evaluating, monitoring, and encouraging) and/or other generic social work functions written as treatment interventions to be delivered social workers (SW) [recovery specialists]. Several intervention statements were identical or similarly worded.

1. Patient A1 had no interventions related psychiatric problems identified to be implemented by the social worker (recovery specialist).

2. Patient A2 had the following generic and/or routine social functions written as treatment interventions instead of individualized interventions reflecting what the social worker would be doing to assist the patient's improvement. The patient's psychiatric evaluation dated 11/1/15 documented that, "...'We have received multiple calls regarding the subject exposing [him/herself] and jumping in front of vehicles...' [Patient ' s name] reports auditory hallucinations that are command in nature." The interventions identified for the following problem included:

Problem #1 - "Speech, behavior, or reports indicating significant danger to self."

SW Interventions (Recovery Specialist): "Identify behavior of violence toward self and place on precautions." "Monitor behavior of violence towards self as it occurs." "Medication/Consults/Referrals."

The social worker/recovery specialist interventions above were routine staff functions and not specific to the patient's improvement and would be provided regardless of the patient's presenting symptoms. The intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist. These intervention statements failed to include whether the intervention would be delivered in individual or group sessions.

3. Patient A3 had the following generic social work intervention written that was not individualized and based on the patient's presenting symptoms. The patient's psychiatric evaluation dated 11/8/15 documented that, "...physically abusive towards [his/her] [spouse] ...threaten [his/her] [spouse] as well as neighbors...While on the unit [s/he] was noted to be angry, disruptive, sexually inappropriate..." The intervention identified for the following problems included:

a. Problem # 1: "Bullying or threatening behaviors."

SW (Recovery Specialist): "Psychoeducation."

The interventions related to "Psychoeducation" did not include a focus of treatment such as what the social worker would be doing to assist the patient to improve based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions).

4. Patient A4 had no interventions related to the psychiatric problem identified to be implemented by the social worker/recovery specialist.

5. Patient A5 had the following identical generic and/or routine discipline functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/9/15 documented that, "...[Patient's name] has threatened to shoot [him/herself] and is violent toward others. [Patient's name] was also observed to throw objects at family members...[Family member's name] reports that [Patient's name] used many drugs but [his/her] drug of choice seems to be crack cocaine...[Patient's name] has expressed visual hallucination as well as stating [s/he] sees bugs crawling on the walls and seeing people who are not there..." The interventions identified for the following problems included:

a. Problem # 1: "Substance abuse / chemical dependency."

SW (Recovery Specialist): "Motivational Enhancement Therapy."

b. Problem #2: "Speech, behavior, or reports indicating significant danger to self."

SW (Recovery Specialist): "Motivational Enhancement Therapy." "MedTEAM (Medication, Treatment, Evaluation, Management)."

c. Problem #3: "Auditory, visual, or tactile hallucinations resulting in impaired functioning."

SW (Recovery Specialist): "Motivational Enhancement Therapy."

Most of the interventions were identified to be "Motivational Enhancement Therapy. This intervention statement did not include a focus of treatment such as what the social worker would be doing to assist the patient to improve based on the patient's presenting symptoms and also did not include a method of delivery (individual or groups sessions).

6. Patient A6 had the following generic and/or routine social work function written as a treatment intervention instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/4/15 documented that, "...presumptive positive for Benzodiazepine...Client reported [s/he] took [his/her] mother medications, [s/he] states, 'I took 4 Xanax and 2 Vicodin' unknown dosages...[S/he] reports [s/he] is hearing a voice telling [him/her] to take [his/her] mother's medications and kill [him/herself]...Client reports multiple suicidal attempts in the past. [S/he] reports taking 175 multiple pills which lead to [him/her] being hospitalized..." The intervention identified for the following problem included:

Problem #2: "Medication management."

SW (Recovery Specialist): "Motivational Enhancement Therapy." This intervention was identified for all three objectives listed for depressed mood.

The intervention related to "Motivational Enhancement Therapy" did not include a focus of treatment to reflect what the social worker would be doing to assist the patient to improve based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions).

7. Patient A7 had the following generic and/or routine social work functions written as treatment interventions instead of individualized interventions based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 10/13/15 documented the following descriptive information: "...[Patient's name] is fixated on paranoid thoughts that others, including [his/her] son, are stealing [his/her] money...reports that this boyfriend has been stealing [his/her] medications and [his/her] Cogentin is missing completely...reports that [s/he] missed [his/her] last Invega injection that was due 10/6/15..." The interventions identified for the following problem included:

Problem #2: "Agitated behavior which client is unable to control."

SW (Recovery Specialist): "Psychoeducation." "Medications/Consults/Referrals."
"MedTEAM (Medication, Treatment, Evaluation, Management."

The interventions related to "Psychoeducation" and "Motivational Enhancement Therapy" were vague, global, and did not include a focus of treatment to reflect what the social worker would be doing to assist the patient to improve based on the patient's presenting symptoms. None of the intervention statements included a method of delivery (individual or groups sessions). The intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist.

8. Patient A8 had the following generic and/or routine social work function written as a treatment intervention instead of an individualized intervention based on the patient's psychiatric symptoms or problems identified upon admission. The patient's psychiatric evaluation dated 11/12/15 documented that, "...Paperwork accompanying individual from the hospital reports that [s/he] took 10-15 pills of 500 mg. penicillin because [s/he] felt like [his/her] family did not want [him/her] to live there...[his/her] mother told nurse that [Patient's name] attempted to kill [him/herself] with a knife 2 days ago...[S/he] reports severe issues with housing and moderate issues with employment,..." The intervention identified for the following problem included:

Problem #3: "Speech, behavior, or reports indicating significant danger to self."

SW (Recovery Specialist): "Medications/Consults/Referrals."

The intervention related to medications was vague, global, and did not include a focus of treatment based on the patient's presenting symptoms. The intervention statement did include a method of delivery (individual or groups sessions). The intervention regarding medications would not be considered to be within the scope of practice for the recovery specialist.

B. Staff Interview

In an interview on 11/17/15 at 1:40 p.m., with the Lead Recovery Specialist, MTPs were discussed. She acknowledged the intervention related to "Motivational Enhancement" Therapy was very broad and did not contain an individualized focus of active treatment based on each patient's presenting symptoms.

III. The Director of Social Work failed to adequately oversee social work roles in treatment and discharge planning. These functions, which were delegated to "Recovery Specialists," none of whom had completed an MSW and who were supervised by a Lead Recovery Specialist who possessed a Bachelor's degree in Psychology. (Refer to B154)

The deficiencies above potentially lead to psychosocial assessments, which are inadequate to guide social work practice and interventions in the inpatient setting as well as social work treatment and discharge planning which may be potentially inadequate for patient needs.

Based upon a review of documents and interviews with staff, the Director of Social Work did not possess a Master's Degree in Social Work, nor did he have an established relationship with an individual who held this credential. This failure potentially led to provision of social work services which were inadequate for patient needs and which did not meet current regulatory guidelines.

Findings are:

Document review:

The curriculum vitae for the Director of Social Work documented that he possessed a Master of Arts in Sociology obtained at Boston College in 1980.

Interviews with Staff:

In an interview with the Director of Social Work on 11/17/2015 at 3:00 p.m. in the Administrator's Conference room, he acknowledged that he did not possess a Master's in Social work nor did he have any established relationship with an individual who held this credential.

In the exit conference held on 11/18/2015 at 12:15 p.m. in the Administrator's Conference Room, the Hospital Administrator acknowledged that there was no individual within the hospital who held an MSW and that the Director of Social Work did not have an established relationship with any individual who possessed this credential.