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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the physician developed individualized interventions on the Master Treatment Plan for two out of 12 medical records reviewed (MR1, MR2); and the facility failed to ensure they employed adequate staff to provide adequate active treatment as evidence by failed to ensure a Master Treatment Plan was developed within 72 hours for one of 12 medical record reviewed (MR7); and failed to ensure the physician, social worker or therapist, and activity therapist developed individualized interventions on the Master Treatment Plan and that the Master Treatment Plan was discussed with the patient/and or family within 72 hours for one of 12 medical records reviewed (MR8.)

Findings include:

Review on December 2, 2020, of facility policy, "Treatment Planning," reviewed October 2020, revealed "Policy: The attending psychiatrist will lead the treatment team in developing each patient's treatment plan based on a thorough assessment of the patient's biological, psychological, psychosocial, environmental, self care, educational and aftercare planning needs. A Master Treatment Plan will be completed by the multidisciplinary treatment team within 72 hours of admission and approved by the attending psychiatrist. Those involved in the treatment planning process include the patient, physician, registered nurse, social worker or therapist, and all other clinical staff involved in the patients care, and when indicated the patient's family, caregivers, or other significant support systems. The interdisciplinary treatment team is responsible for development of the individualized treatment plan and the review and evaluation of ongoing treatment. This is coordinated by the patient's social worker or therapist. The treatment plan will be reviewed and updated as needed, but no less than once a week, and any changes will be documented on the plan. The Master Treatment Plan must be reviewed with the patient and/or his family or legal guardian and signed and dated within 72 hours of admission. ...The multidisciplinary treatment planning process incorporates the plan of care for each discipline, thereby eliminating the need for separate planning documents for any discipline. Purpose: 1. To identify the patient's clinical needs and problems and provide a vehicle for continuous reassessment. 2. To establish a mechanism for interdisciplinary collaboration concerning identified problems, priorities, goals and interventions. 3. To identify a multidisciplinary clinical approach toward meeting established patient goals and to assure a consistent approach among providers. 4. To establish a mechanism to review the proposed plan of care with the patient and family (if appropriate) and to gain their cooperation and involvement, as appropriate. 5. To provide a mechanism to monitor patient progress, to reassess the problem list. ... Procedure: ...B. Master Treatment Plan: 1. A Master Treatment Plan based on the assessment of the patient's presenting problems, physical health, emotional status and behaviors identified by clinical assessments completed in the first 72 hours of treatment, will be developed within 72 hours of admission. 2. Problems will be transferred from the Master Problem List and from other clinical documents to the Master Treatment Plan listed in priority of patient needs. 3. Working diagnosis (determined by the attending psychiatrist) and the patient's strengths and assets presented will be identified. 4. Measurable and obtainable expected outcomes, which are based on the patient problems and defined considering the expected length of stay, will be formulated, and discharge plans and goals for post hospitalization will be identified. 5. Family and/or collaborative involvement by individuals or agencies outside the hospital will be listed and the involvement in the treatment process identified. 6. The specific interventions to help the patient meet the expected outcomes will be listed and will include the therapeutic modality to be provided, by whom, and frequency. ..."

1) Review on December 2, 2020, of MR1 revealed a Master Treatment Plan initiated on November 19, 2020. The problem identified on the initial assessment was suicidal thoughts. There were no individual patient-focused interventions completed by the physician.

Review on December 2, 2020, of MR2 revealed a Master Treatment Plan was initiated on November 28, 2020. The problem identified on the initial assessment was depression. There was no documentation of individual patient-focused interventions completed by the physician.

Interview on December 2, 2020, at approximately 11:00 AM, with EMP3 confirmed MR1 and MR2 had no documentation of individual patient-focused interventions completed by the physician.

2) Review on December 2, 2020, of the facility, "Published Opportunities,", revealed the facility had two open Senior Inpatient Therapist positions dated October 19, 2020 and three open Inpatient Social Worker positions dated November 18, 2020.

Interview on December 2, 2020, at approximately 1:00 PM, with EMP2 confirmed two Senior Inpatient Therapist positions were posted dated October 19, 2020 and three Inpatient Social Worker positions were posted dated November 18, 2020. EMP2 revealed a fourth Inpatient Social Worker position is available as someone was not able to take that position and it had not been reposted yet.

Review on December 2, 2020, of MR7 revealed this patient was admitted on November 21, 2020, with major depressive disorder. There was no documentation a Master Treatment Plan was developed within 72 hours.

Interview on December 2, 2020, at approximately 1:00 PM, with EMP3 and EMP4 confirmed there was no documentation a Master Treatment Plan was developed within 72 hours for MR7.

3) Review on December 2, 2020, of MR8 revealed a Master Treatment Plan was initiated on November 24, 2020. The problem identified on the initial assessment was suicide [Sic] thoughts. There was no documentation of individual patient-focused interventions completed by the physician, social worker or therapist, and activity therapist. There was no documentation the Master Treatment Plan was discussed with MR8 and/or family.

Interview on December 2, 2020, at approximately 11:45 AM, with EMP3 confirmed MR8 had no documentation of individual patient-focused interventions completed by the physician, social worker or therapist, and activity therapist. EMP3 confirmed there was no documentation MR8's Master Treatment Plan was discussed with MR8 and/or family.

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to follow the job description for the director of social services for one of one applicable personnel file (PF3.)

Findings include:

Review on December 3, 2020, of facility position description 20 (date not filled in), "Director-Social Services Inpatient Wilkes-Barre Behavioral Hospital," revised May 2014, revealed "Position Purpose Under the administrative supervision of the Chief Executive Officer and the clinical supervision of the Medical Director, the Director of Clinical Social Work monitors the ongoing provisions of department clinical services through supervision and consultation to staff, maintains relationship with community agencies and provides clinical services, as needed. ...Experience/Specialized Skills/Aptitudes Minimum five (5) years clinical social work experience is required ..."

Interview on December 2, 2020, at approximately 9:00 AM with EMP1, EMP2, and EMP3 revealed EMP6 is the interim Director of Social Services.

Review on December 3, 2020, of PF3 revealed a position description for the Director-Social Services Inpatient Wilkes-Barre Behavioral Hospital signed by EMP6 on October 10, 2020. There was no documentation in PF3 that EMP6 had five years of clinical social work experience.

Review on December 4, 2020, of email documentation from EMP5 on December 3, 2020 at 4:41 PM confirmed EMP6 does not meet the social work requirements as per the job description.