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Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided for 5 (biohazardous waste disposal, fire extinguisher service, fire alarm monitoring and maintenance, elevator service, and a registered dietitian) of 12 contracted services.

Findings:

1. The list of contracted services provided by administrative assistant A5 failed to indicate a provider for biohazardous waste disposal, fire extinguisher service, fire alarm monitoring and maintenance, elevator service, and a registered dietitian.

2. Review of facility documentation indicated the following: biohazardous waste disposal by CS1, fire extinguisher and fire panel monitoring and service by CS2, elevator service by CS3, and a registered dietitian agreement with CS4.

3. During an interview on 6-25-14 at 1445 hours, staff A2, nursing director confirmed that the list of contracted services lacked a provider for the indicated inpatient contracted services and had not been maintained.

Based on document review and interview, the policy/procedure regarding patient grievances failed to distinguish when a patient complaint shall be considered an grievance and failed to assure that the patient or the patient's representative was informed of the facility representative with whom to file a grievance and informed how to submit a grievance with the Indiana State Department of Health (ISDH).

Findings:

1. The policy/procedure Customer Relations (approved 3-14) failed to indicate all conditions and circumstances when a patient complaint shall be regarded as a grievance by the facility.

2. The policy/procedure Customer Relations (approved 3-14) and Patient Rights (approved 11-01) failed to ensure that all patients and /or the patient representative were provided notice or title of a responsible person at the facility with whom to file a grievance and notice of how to file a grievance with the Indiana State Department of Health (ISDH).

3. The document file Patient Rights Voluntary (revised 2-11) identified as the facility notice of patient rights failed to indicate a name or title of a responsible person at the facility with whom to file a grievance and failed to indicate how to file a grievance with the Indiana State Department of Health (ISDH).

4. During an interview on 6-26-14 at 1330 hours, customer relations and practice management A3 confirmed that the policy/procedures lacked the indicated requirements and confirmed that the notice of patient rights document failed to indicate a facility representative with whom to submit a grievance and failed to indicate how to file a grievance with the Indiana State Department of Health (ISDH) including a phone number and address.

Based on document review and interview, the facility failed to establish a clearly explained procedure for submitting a verbal or written grievance by a patient or patient's representative.

Findings:

1. The policy/procedure Customer Relations (approved 3-14) and Patient Rights (approved 11-01) failed to ensure that notice of how to submit a verbal or written grievance to the facility was provided to a patient or patient ' s representative.

2. The document file Patient Rights Voluntary (revised 2-11) identified as the facility notice of patient rights failed to indicate how to file a grievance with a representative of the facility including contact information.

3. During an interview on 6-26-14 at 1430 hours, customer relations and practice management A3 confirmed that the policy/procedures and patient rights notice failed to indicate a procedure for submitting a verbal or written grievance to the facility.

Based on document review and interview, the policy/procedure regarding patient grievances failed to assure that the facility would always provide a written notice of its decision to the patient or their representative.

Findings:

1. The policy/procedure Customer Relations (approved 3-14) indicated the following: "Within 30 days of the complaint being documented, the supervisor will contact the consumer to discuss their concerns. If the consumer is not available, feedback will be shared with the consumer in writing." The policy/procedure failed to indicate the requirement to provide written notice of the facility's decision for all grievances.

2. During an interview on 6-26-14 at 1435 hours, customer relations and practice management A3 confirmed that the policy/procedure failed to require a written response for all grievances submitted to the facility.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure the implementation of the restraint and seclusion policy, in regards to the lack of a restraint order, for 1 of 2 adolescent charts reviewed, and 1 of 1 with a restraint episode (pt. #8).

Findings:
1. Review of the document titled "Restraint and Seclusion", (no policy number), with a last revision date of 8/11, indicated:
a. On page one under "Policy", it reads: "...Restraint and seclusion shall not be ordered simultaneously."
b. On page 3, under the section "Provider Orders for Patients Exhibiting Violent or Self Destructive Behavior", it reads: "A. Provider orders will be obtained...2. Type of restraint or seclusion...".

2. Review of the medical record for patient #8, an 11 year old, indicated that on 3/31/14:
a. In the area of the electronic medical record that read: "Provider Order"..."Note text of Provider's Order:": "Place patient in age appropriate time-out/seclusion."
b. In the area of the electronic medical record that read: "Provider's recommendations for management:": "Patient placed in seclusion for 10 minutes, then re-evaluate behavior.".
c. Under "Intervention", it reads: "Manual - Hold Seclusion"; "Manual Restraint, Date In: 03/31/2014"; "Manual Restraint, Time in: 1:45 PM"; "Manual/Physical Hold - check the intervention:": "Four limb hold"; "Seclusion, Date In: 03/31/2014"; "Seclusion, Time In: 1:45 PM".

3. At 1:30 PM on 6/26/14, interview with staff member #51, the Service Records Supervisor, indicated:
a. The order reads for a time out/seclusion, and not a manual hold/"four limb hold" that was noted in the medical record.
b. It appears that the patient had a four limb hold, as well as being in seclusion, at 1:45 PM on 3/31/14, but only an order for seclusion was received.
c. When a patient is in four point restraints, they are always in the seclusion room, and considered "in seclusion". (the policy listed in 1.a. above, indicates that the facility does not allow restraint and seclusion to occur simultaneously)
d. The "Discontinuation Order" was written at 1:55 PM for: "Discontinue seclusion", but does not address the four limb hold that was documented as having been implemented by staff.

Based on policy and procedure review, document review, medical record review, and interview, the nursing supervisor failed to ensure the implementation of policies and physician orders for one patient with orders for substance abuse vital signs and the monitoring of vital signs for patients in detoxification for 1 (pt. #1) of 8 patients, and 1 of 2 with orders for substance abuse vitals signs orders (pt. #1).

Findings:
1. Review of the policy (title "Training Document"), "Monitoring Vital Signs For Detoxification Services", no policy number, with a last reviewed date of 4/02, indicated:
a. Under "Purpose", it reads: "To monitor a patient's body systems during the detoxification process via the periodic taking of vital signs. Thus early intervention and additional medical care can be implemented when indicated to insure a safe detoxification process.".
b. Under "Steps", it reads: "...2. When indications are present that detoxification is necessary the Nurse will secure orders from the physician for vitals signs to be monitored and recorded every four (4) hours for the first 24 hours (including night shift) after admission and then every shift thereafter...".

2. Review of the document titled "Procedure: Clinical Institute Withdrawal Assessment Of Alcohol Scale" (CIWA) with a last reviewed date of 5/01 (no policy number), indicated:
a. "...If score is less than 10 after two 8-hour reviews, monitoring can stop...".

3. Review of the standing order sheets titled "Provider Orders" indicated that Substance Abuse Vital Signs are to be taken "Every 4 hours x 24 hours".

4. Review of patient #1's medical record indicated:
a. The patient was admitted on 4/16/14 with admission orders written at 5:35 AM.
b. An order was written at 1:30 PM on 4/17/14 for: "Substance Abuse Vitals - Phenobarbital 130 mg IM (intramuscularly) per CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) 10 or greater q (every) 3 hrs (hours)".
c. After the 1:30 PM order for Substance abuse vitals every 4 hours, there was a gap between the 9:30 PM vitals on 4/17/14 and the next set of vitals taken at 6:49 AM on 4/18/14; the next gap (greater than 4 hours) was between those of 8:12 AM and the next set at 1:06 PM.
d. After the 1:30 PM order for CIWA assessments on 4/17/14, which were to be performed every 3 hours, the first assessment was at 1:45 PM and the next at 4:45 PM when the patient scored at a 10 and was given 130 mg Phenobarbital.
e. There were no further every three hour CIWA assessments done for pt. #1 after the 4:45 PM assessment on 4/17/14.
f. A nursing note was made at 9:42 PM on 4/17/14, but lacked any documentation of vital signs or CIWA assessment.

5. At 2:25 PM on 6/25/14, interview with staff members #51, the Service Records Supervisor, and #53, the director of nursing, indicated:
a. Vital signs were greater than every 4 hours for pt. #1 when physician orders for the substance abuse vital signs was for every four hours.
b. It was thought that it would be OK for nursing to document the patient sleeping on the night shift and to not take vital signs as ordered, but the substance abuse orders do not indicate that the night shift has this leverage.
c. CIWA orders specifically required assessments on the night shift (see 1. b. above), but the policy/orders were not followed by nursing as only two CIWA assessments were performed, and the patient scored at a 10 with the second assessment and required medication administration.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure the implementation of the restraint and seclusion policy, in regard to the lack of a complete one hour face to face evaluation performed, for 1 of 2 adolescent charts reviewed, and 1 of 1 with a restraint episode (pt. #8).

Findings:
1. Review of the document titled "Restraint and Seclusion", (no policy number), with a last revision date of 8/11, indicated:
a. Under the topic "Evaluation and Re-evaluation:", it reads: "The responsible provider or trained RN (registered nurse), within one (1) hour of the initiation of the restraint or seclusion will conduct a face to face evaluation of the patient as follows:...c. Evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and whether restraint or seclusion shall be continued;...".

2. Review of the medical record for patient #8, an 11 year old, indicated that a restraint (four point limbs) and seclusion occurred from 1:45 PM to 1:55 PM on 3/31/14, and had a face to face evaluation at 2:15 PM that lacked documentation that there was evaluation of the patient's: "immediate situation", "reaction to the intervention", "behavioral condition", and "whether restraint or seclusion shall be continued".

3. At 1:30 PM on 6/26/14, interview with staff member #51, the Service Records Supervisor, indicated:
a. The medical record documentation for the face to face evaluation for patient #8, for the event at 1:45 PM on 3/31/14, lacked documentation of evaluation of the patient's "immediate situation", "reaction to the intervention", "behavioral condition", and "whether restraint or seclusion shall be continued", as required by facility policy.

Based on document review and interview, the governing body failed to ensure that all services were evaluated and reviewed through the Quality Assessment and Performance Improvement (QA) program for 1 direct service (housekeeping) and 4 contracted services (fire alarm and control services, laboratory, laundry, and registered dietitian).

Findings:

1. The policy/procedure Quality Assessment and Performance Improvement Plan (approved 4-05) indicated the following: "The individual and aggregate review of services and care and utilization includes ...review of contracted services and regular internal services provided."

2. QA program documentation failed to indicate monitoring and periodic reporting for the internal inpatient service of housekeeping (environmental services) and for the contracted fire alarm and fire extinguisher services, laboratory, laundry, and registered dietitian services.

3. During an interview on 6-25-14 at 1630 hours, facilities director A10 confirmed that no documentation of periodic evaluation for the fire alarm and control provider was available.

4. During an interview on 6-26-14 at 1545 hours, the QA director A4 confirmed that the QA program documentation lacked evidence of periodic monitoring and review for the registered dietitian, housekeeping, laboratory or laundry services.

Based on document review and interview, the medical staff failed to ensure that revisions to its medical staff bylaws were submitted and approved by the governing board.

Findings:

1. The medical staff bylaws indicated that a revision to the medical staff bylaws was approved by the governing board on 11-30-10 and no documentation indicated that the medical staff-approved revisions dated 7-13-12 and 5-8-14 were reviewed and approved by the governing board.

2. Governing board meeting minutes dated 5-27-14 and 6-24-14 failed to indicate that the revised medical staff bylaws were presented and approved by the governing board.

3. During an interview on 6-26-14 at 1400 hours, customer relations and practice management A3 confirmed that the bylaws lacked evidence of governing board approval and no further documentation was available.

Based on policy and procedure review, document review, medical record review, and interview, the nursing supervisor failed to ensure the implementation of policies and physician orders for one patient with orders for substance abuse vital signs and the monitoring of vital signs for patients in detoxification for 1 (pt. #1) of 8 patients, and 1 of 2 with orders for substance abuse vitals signs orders (pt. #1).

Findings:
1. Review of the policy (title "Training Document"), "Monitoring Vital Signs For Detoxification Services", no policy number, with a last reviewed date of 4/02, indicated:
a. Under "Purpose", it reads: "To monitor a patient's body systems during the detoxification process via the periodic taking of vital signs. Thus early intervention and additional medical care can be implemented when indicated to insure a safe detoxification process.".
b. Under "Steps", it reads: "...2. When indications are present that detoxification is necessary the Nurse will secure orders from the physician for vitals signs to be monitored and recorded every four (4) hours for the first 24 hours (including night shift) after admission and then every shift thereafter...".

2. Review of the document titled "Procedure: Clinical Institute Withdrawal Assessment Of Alcohol Scale" (CIWA) with a last reviewed date of 5/01 (no policy number), indicated:
a. "...If score is less than 10 after two 8-hour reviews, monitoring can stop...".

3. Review of the standing order sheets titled "Provider Orders" indicated that Substance Abuse Vital Signs are to be taken "Every 4 hours x 24 hours".

4. Review of patient #1's medical record indicated:
a. The patient was admitted on 4/16/14 with admission orders written at 5:35 AM.
b. An order was written at 1:30 PM on 4/17/14 for: "Substance Abuse Vitals - Phenobarbital 130 mg IM (intramuscularly) per CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) 10 or greater q (every) 3 hrs (hours)".
c. After the 1:30 PM order for Substance abuse vitals every 4 hours, there was a gap between the 9:30 PM vitals on 4/17/14 and the next set of vitals taken at 6:49 AM on 4/18/14; the next gap (greater than 4 hours) was between those of 8:12 AM and the next set at 1:06 PM.
d. After the 1:30 PM order for CIWA assessments on 4/17/14, which were to be performed every 3 hours, the first assessment was at 1:45 PM and the next at 4:45 PM when the patient scored at a 10 and was given 130 mg Phenobarbital.
e. There were no further every three hour CIWA assessments done for pt. #1 after the 4:45 PM assessment on 4/17/14.
f. A nursing note was made at 9:42 PM on 4/17/14, but lacked any documentation of vital signs or CIWA assessment.

5. At 2:25 PM on 6/25/14, interview with staff members #51, the Service Records Supervisor, and #53, the director of nursing, indicated:
a. Vital signs were greater than every 4 hours for pt. #1 when physician orders for the substance abuse vital signs was for every four hours.
b. It was thought that it would be OK for nursing to document the patient sleeping on the night shift and to not take vital signs as ordered, but the substance abuse orders do not indicate that the night shift has this leverage.
c. CIWA orders specifically required assessments on the night shift (see 1. b. above), but the policy/orders were not followed by nursing as only two CIWA assessments were performed, and the patient scored at a 10 with the second assessment and required medication administration.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure the implementation of the policy related to the timing and authentication of doctor's orders for 5 of 8 patient records reviewed (pts. #1, 4, 5, 6 and 7).

Findings:
1. Review of the document titled:"Training Document", "Doctor's Orders", with a date of origin 6/14, (no policy number), indicated:
a. In the "Procedure" area, it reads: "...4. All Doctor's Orders shall be dated and timed. 5. A Physician shall authenticate [sign/date/time] their entries; verbal orders given to a Nurse, and any orders recorded by the Nurse Scribe within 24 hours."

2. Review of patient medical records indicated:
a. Pt. #1 had a TO (telephone order) written at 2235 hours on 4/17/14 that was authenticated on 4/18/14 by the practitioner, but lacked a time of authentication.
b. Pt. #4 had a TO written at 2045 hours on 4/4/14 that was authenticated on 4/5/14 by the practitioner, but lacked a time of authentication.
c. Pt. #5 had an order written by nursing staff on 4/4/14 that lacked a time of the order and lacked a time of authentication by the practitioner.
d. Pt. #6 had an order for "4 -way restraints" on 4/12/14 at 2:00 PM that was not authenticated until 4/14/14 at 5:23 AM.
e. Pt. #7 had:
A. An order by nursing staff on 4/4/14 that lacked a time of the order and lacked a time of authentication by the practitioner on 4/5/14.
B. Two orders written on 4/6/14, one at 0635 hours and one at 1855 hours, that were authenticated by the physician on 4/7/14, but lacked a time of authentication.

3. Interview with staff member #51, the service records and quality manager, at 1:45 PM on 6/26/14, indicated:
a. The telephone and verbal orders listed in 2. above were lacking a time of authentication by the physician.
b. The orders for patients #5 and #7 lacked a time of the order written by nursing staff.
c. The restraint order for patient #6 was not authenticated within 24 hours, as required by facility policy.

Based on document review, patient medical record review, and staff interview, the facility failed to ensure that a history and physical was completed, updated, and/or present in the medical record, for 3 of 8 patients (pts. #2, #3, and #8).

Findings:
1. Review of the document titled: "Medical Staff Committee", (considered the facility physician by-laws and rules/regulations), with a revised/accepted date on 5/8/14 by the "Medical Staff Committee", indicated:
a. In item #3., it reads: "Physical examinations with appropriate lab studies will be completed within 24 hours. If there is documentation of a physical examination performed within the last thirty days by another doctor who is not a member of the [facility] medical staff, the Provider will review that examination and update information, where appropriate, date and sign the physical examination with amendments or approve as received.".

2. Review of patient medical records indicated:
a. Pt. #2 was admitted on 4/19/14, discharged on 4/22/14, and lacked a physical examination document in the medical record. (In the "Physical Exam section of the chart, it read: "A physical exam was performed and documented".)
b. Pt. #3 was admitted on 4/23/14 at 3:06 AM, discharged on 4/24/14 at 2:45 PM, and lacked a physical examination in the medical record. (In the "Physical Exam section of the chart, it read: "A physical exam was performed at [local] hospital and was found to be adequate.")
c. Pt. #8 was admitted on on 3/29/14 and had a physical in the medical record that was dated 3/22/14, but lacked dating and signing by the admitting physician to indicate whether there were any changes or updates to be noted between the time of 3/22/14 and 3/29/14. (The psychiatrist wrote, in the physical exam portion of the chart: "A physical exam was performed and documented.", but lacked any update or signature on that document.)

3. Interview with staff member #51, the service records and quality manager, at 1:45 PM on 6/26/14, indicated:
a. The "history" portion of a history and physical is performed by the psychiatrist.
b. The "physical" portion of a history and physical is accepted by psychiatrists at this facility as the one performed in the emergency department of the local acute care hospital.
c. Patient #2 was admitted voluntary (signed in by parent/guardian) and did not come through the emergency department, so that a physical examination was not documented and present in the medical record, even though the psychiatrist documented that one was "performed".
d. The physical dated 3/22/14 for patient #8 lacked an update note and authentication by the psychiatrist upon admission of the patient on 3/29/14, as required by facility policy.

Based on review of the "medical staff committee" document (medical staff by-laws and rules and regulations), patient medical record review, and staff interview, the medical staff failed to ensure that a final diagnosis/discharge summary was completed for 1 of 8 patients (pt. #3) and 1 of 2 for MD#59 (pt. #3).

Findings:
1. Review of the document titled :"Medical Staff Committee", the facility physician by-laws and rules/regulations, with a revised/accepted date on 5/8/14 by the "Medical Staff Committee", indicated
a. Item 11. reads: "Any chart not completed (including dictation and signatures) within fifteen days following discharge, will be considered delinquent...".

2. Review of the medical record for patient #3 indicated:
a. This patient was admitted at 3:06 AM on 4/23/14 and discharged to home at 2:45 PM on 4/24/14.
b. There was no discharge summary in the on line medical record for this patient.

3. Interview with staff members #51, the Services Records and Quality manager, and #53, the director of nursing, at 4:10 PM on 6/25/14, indicated:
a. Patient #3 was admitted to the facility for approximately 36 hours.
b. There is no discharge summary for patient #3.
c. The medical staff document (listed in 1. above) does not specifically address what is required in the way of a discharge summary, and in particular for those with a short (<48 hours) stay, but it is expected that one will be completed within the fifteen day timeframe stated in the document.

Based on diet manual review, contract review, and staff interview, the facility failed to ensure there was a qualified dietician on staff.

Findings:
1. At 4:00 PM on 6/26/14, review of the dietary manual from the nursing unit indicated that a list of types of diets available for clients was in the front of the binder, but lacked any documentation indicating the dietician had approved the diet types.

2. The contract for the dietician was dated October 2013.

3. At 4:10 PM on 6/26/14, interview with staff member #53, the director of nursing, indicated:
a. The current contracted dietician started at the facility in October 2013, but has "not actually begun services" to the facility.
b. There is no evidence that the dietician gave approval to the diets listed in the dietary manual located on the nursing unit.
c. There is no documentation, or evidence, that the contracted dietician has fulfilled the duties as listed in the contract signed in October, 2013.
d. The facility has been without a dietician's services for 9 months.

Based on observation and interview, the facility failed to provide documentation that the dietary manual was approved by the dietician and medical staff.

Findings:
1. At 4:00 PM on 6/26/14, review of the dietary manual from the nursing unit indicated that a list of types of diets available for clients was in the front of the binder, but lacked any documentation indicating the dietician, or the medical staff, had approved the diet types.

2. At 4:10 PM on 6/26/14, interview with staff member #53, the director of nursing, indicated:
a. There is no evidence that the dietician, or medical staff, gave approval to the diets listed in the dietary manual located on the nursing unit.

Based on Life Safety Code (LSC) survey, Grant-Blackford Mental Health, Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This two story facility with a lower level was determined to be of Type II (222) construction and was partially sprinklered. The lower level was sprinklered with the main floor and inpatient floor being nonsprinklered. The facility has a fire alarm system with smoke detectors on all levels throughout the corridors. The facility has a capacity of 16 beds and had a census of 2 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure materials used as an interior finish in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants (see K 014), failed to ensure materials used as an interior finish in rooms and spaces not in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants (see K 015), failed to ensure 4 of 60 corridor doors closed and latched automatically into the door frame to protect all occupants and 2 of 60 corridor doors were capable of resisting smoke to protect all occupants (see K 018), failed to ensure 2 of 2 pharmacy pass-through windows did not exceed 20 square inches in the aggregate area of the room (see K 019), failed to ensure 2 of 5 doors serving hazardous areas such as an area exceeding 50 square feet and storing quantities of combustible materials automatically closed and latched to prevent the passage of smoke (see K 029), failed to conduct quarterly fire drills on each shift for 1 of 4 quarters and conduct fire drills under varied conditions in 10 of 10 fire drills (see K 050), failed to ensure 1 of 6 smoke detectors located on the main floor and connected to the fire alarm system was properly separated from an air supply or return vent (see K 051), failed to inspect 2 of 15 portable fire extinguishers each month (see K 064), failed to ensure curtains throughout the facility were flame retardant (see K 074), failed to ensure 2 of 3 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart (see K 076) and failed to exercise the generator for 12 of 12 months and failed to provide emergency task lighting in and around the generator, failed to ensure 1 of 1 emergency generators was provided with a functioning remote alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 1 of 1 emergency generators with over 100 horsepower was equipped with a remote manual stop (see K 144).

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

Based on observation, interview and record review, the facility failed to ensure materials used as an interior finish in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants, failed to ensure materials used as an interior finish in rooms and spaces not in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants, failed to ensure 4 of 60 corridor doors closed and latched automatically into the door frame to protect all occupants and 2 of 60 corridor doors were capable of resisting smoke to protect all occupants, failed to ensure 2 of 2 pharmacy pass-through windows did not exceed 20 square inches in the aggregate area of the room, failed to ensure 2 of 5 doors serving hazardous areas such as an area exceeding 50 square feet and storing quantities of combustible materials automatically closed and latched to prevent the passage of smoke, failed to conduct quarterly fire drills on each shift for 1 of 4 quarters and conduct fire drills under varied conditions in 10 of 10 fire drills, failed to ensure 1 of 6 smoke detectors located on the main floor and connected to the fire alarm system was properly separated from an air supply or return vent, failed to inspect 2 of 15 portable fire extinguishers each month, failed to ensure curtains throughout the facility were flame retardant, failed to ensure 2 of 3 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart and failed to exercise the generator for 12 of 12 months and failed to provide emergency task lighting in and around the generator, failed to ensure 1 of 1 emergency generators was provided with a functioning remote alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 1 of 1 emergency generators with over 100 horsepower was equipped with a remote manual stop.

Findings:

1. Observation with POM1 (Plant Operations Manager) during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted the Therapist office on the main floor had two corridor walls constructed with a wood lattice material.

2. Interview with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. revealed no documentation was immediately available to demonstrate the wood lattice material exhibited a flame spread classification of Class A or B.

3. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted the following:
a. The Registration office on the main floor had a wall covered by corkboard which was being used as an interior finish.
b. The walls of the copy room on the main floor were covered by a fiber wallcovering material being used a an interior finish.

4. Interview with POM1 after the observation revealed documentation was not available to demonstrate the materials used as an interior finish exhibited a flame spread classification of Class A or B.

5. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted following:
a. The clean linen room on the inpatient floor had a set of double corridor doors. The inactive leaf was equipped with a manual flush bolt latch which required a manual operation to allow the active leaf to latch into the inactive leaf.
b. The Medical Clinic room on the main floor had a dutch door. The upper half of the door was equipped with a slide bolt that required a manual operation to latch the upper half of the door.
c. The Main Office on the main floor had a dutch door and a 4 foot by 3 foot opening that was provided with doors or shutters that could be closed. The upper half of the dutch door was equipped with a slide bolt that required a manual operation to latch the upper half of the door. The doors or shutters in the opening were also equipped with slide bolts that required a manual operation for latching.

6. In interview at the time of observation, POM1 acknowledged the aforementioned
conditions.

7. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. indicated the set of double doors to the clean linen room on the inpatient floor had a 3/8 inch gap between the doors.

8. In interview at the time of observation, POM1 acknowledged the gap exceeded 1/8 of an inch and would not resist the passage of smoke.

9. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. indicated the pharmacy had two 12 inch by 12 inch windows with fixed-wire, sliding glass panels that exceeded 20 square inches in total aggregate area.

10. LSC 19.3.6.5 allows miscellaneous openings to be installed in vision panels or doors without special protection, provided the aggregate area of the openings per room does not exceed 20 square inches and the openings are installed at or below half the distance from the floor to the room ceiling.

11. In interview at the time of observation, POM1 acknowledged the aforementioned condition.

12. During observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The door serving the Records room on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for storage of a large quantity of paper files.
b. The door serving room 30 on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for the storage of at least 80 cardboard boxes of patient files.

13. In interview at the time of observation, POM1 acknowledged the aforementioned conditions.

14. Review of "Risk Management Reports" with POM1 from 1:45 p.m. to 3:45 p.m. on 06/25/14 indicated documentation of fire drills was not available to review for the first and second shifts of the third quarter of 2013.

15. In interview at the time of record review, POM1 acknowledged the fire drill reports were in the process of being transferred and the documentation was not available for review to verify drills during these time periods were conducted.

16. Review of "Risk Management Reports" with POM1 from 1:45 p.m. to 3:45 p.m. on 06/25/14 indicated fire drills conducted over the past four quarters were not held at random times on each shift. Three of three first shift drills conducted over the past 4 quarters were between 10:00 a.m. and 10:35 a.m.; three of three second shift drills conducted over the past 4 quarters were between 5:00 p.m. and 5:15 p.m. and four of four third shift drills conducted over the past 4 quarters were between 6:00 a.m. and 6:30 a.m.

17. In interview at the time of record review, POM1 acknowledged the aforementioned condition.

18. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted the smoke detector located near the pharmacy was one foot from an air supply vent.

19. In interview at the time of observation, POM1 acknowledged the distance between the vent and agreed the air flow could interfere with smoke detector function.

20. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted the following:
a. The monthly inspection tag on the fire extinguisher located in the cabinet next to the main floor north exit stairwell lacked documentation of a monthly inspection for the month of May of 2014.
b. The monthly inspection tag on the fire extinguisher located in the lower level telephone equipment room lacked documentation of a monthly inspection for the months of April and May of 2014.

21. In interview during the times of observation, POM1 acknowledged the monthly inspections had been missed.

22. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted curtains in rooms 211, 214, 215, 216, 217, 227, 228, 229, 230, 231, 232 and in the inpatient exam room and dining room lacked attached documentation indicating they were inherently flame retardant.

23. In interview at the time of observation with POM1, there was no documentation regarding flame retardancy for the aforementioned curtains available for review.

24. During observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., it was noted there were three oxygen E-cylinders in the inpatient exam room. Two of the three cylinders were standing in the corner of the room without support.

25. In interview at the time of observation, POM1 acknowledged the cylinders should have been in stands or chained to the wall.

26. Based on review of generator load testing documentation with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Plant Operations Manager acknowledged the generator ran under load on a weekly basis but does not achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator had not occurred within the past year.

27. Observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. indicated the generator set was inside an enclosure within a fenced area and was not provided with a battery powered emergency light for task lighting.

28. In interview at the time of observation, POM1 acknowledged battery powered emergency task lighting was not provided.

29. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. indicated a remote alarm annunciator for the generator was provided at the inpatient nurse station, but was not functional.

30. In interview at the time of observation, POM1 acknowledged the generator remote annunciator was not functional and indicated the generator is slated to be replaced and will have a compliant annunciator.

31. Observation with POM1 during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m. noted the generator in the exterior enclosure was not equipped with a remote manual stop switch.

32. In interview at the time of observation, POM1 acknowledged the generator engine provides more than 100 horsepower and lacked a remote manual stop station.

Based on document review, employee file review, and staff interview, the infection control committee failed to: ensure that the ICP (staff member N2) was qualified for the position, have a job description that would explain the expectations and duties of the ICP position, ensure that the committee and ICP developed an effective infection control plan.

Findings:
1. Review of the facility "Exposure Control plan", no policy number, with a last revision date of 11/01, indicated this document had segments related to infection control practices, but did not give any indication of indicators the facility had chosen to measure themselves by.

2. Review of 2013 and 2014 infection control meeting minutes indicated:
a. The meeting minutes of November 20, 2013 indicated, in a "Topic Discussion" section, that "[staff member N2] will take over the chair" of the committee and the ICP position.

3. Review of the employee file for the ICP, staff member N2, indicated there was:
a. An April 2013 training attended related to "How Nutrients Affect Mental Health and the Brain", but no other education or training specific to the duties and responsibilities of being the ICP for the facility.
b. No job description for the ICP position that would explain the expectations and duties of the position.

4. At 9:35 AM on 6/26/14, interview with staff member #51, the Service Records Supervisor, indicated:
a. The Exposure Control Plan was thought to be able to be used by the facility as an infection control plan.

5. Interview at 1:30 PM on 6/26/14 with staff member #53, the director of nursing, indicated:
a. Staff member N2 just became ICP "in the last few months", it was thought to be about January 2014. (see item #2 above to note that N2 became ICP in November of 2013)
b. The ICP job description is "in process".

Based on document review, observation, and interview, the infection control practitioner (ICP) and infection control committee failed to ensure that the CEO (chief executive officer) and medical staff were involved in infection control activities; failed to ensure that infection control committee minutes were specific to the inpatient unit; failed to ensure the oversight and approval of products utilized by housekeeping staff to maintain a sanitary environment; failed to ensure the cleanliness of the nursing unit (specifically one supply cart); and failed to ensure that nursing staff were cleaning the glucometer with the appropriate product after each use.

Findings:
1. Review of the 2013 and 2014 infection control committee meeting minutes indicated:
a. Of the four meetings held in 2013, the May 22, 2013 and September 4, 2013 meetings listed the physician as "absent". (The November 20, 2013 meeting miintues stated a physician was "welcomed to the Committee", but did not list them as being present)
b. The January 22, 2014 meeting minutes did not list a physician as either present or absent.
c. The June 4, 2014 meeting minutes did not list a physician as present, but on page two, the medical director was documented as "...gave a brief summary on all types of Hepatitis...".
d. The CEO was not listed as present at any of the meetings.
e. The four 2013 and two 2014 infection control committee meeting minutes have aggregate reporting of infections and issues, with the outpatient data, group/residential home data, and inpatient data and statistics all combined, making it impossible to determine actual information and activities specific to the inpatient unit.

2. At 3:30 PM on 6/26/14, interview with staff members #51, the Service Records Supervisor, and #57, the plant operations and safety director, indicated:
a. Staff member #57 is the supervisor for the housekeeping staff.
b. The infection control committee and ICP have not approved of cleaning products, and cleaning processes and practices, as part of infection control activities/responsibilities.

3. At 10:15 AM on 6/26/14, while on tour of the nursing unit in the company of staff member #58, the RN (registered nurse) on the unit, it was observed in a locked area:
a. A supply cart, with the AED (automated external defibrillator) on top, was found to be dusty/dirty on the top of the cart, and with > 4 four to five inch hairs on the top, and with each of the drawers of the cabinet extremely dusty/dirty.

4. Interview with staff member #58, the unit RN, at 10:20 AM on 6/26/14 indicated:
a. There is no scheduled cleaning process for the cart.
b. The glucometer is cleaned after each patient use using an alcohol swab.

5. Review of the policy and procedure titled "Training Document", "Clean Blood Gluscose (sic) Machine", no policy number, with a last reviewed date of 12/11, indicated:
a. under "Procedure", it reads: "1. Disinfect using 10% bleach solution (9 parts water, 1 part bleach) and remove with water. Do not immerse the meter or hold under running water. Do not use cleansers or glass cleaner with ammonia...".

6. Interview with staff member #53, the director of nursing, at 11:55 AM on 6/26/14 indicated:
a. There is a discrepancy between the policy instructions for cleaning the glucometer, and what the RN on the unit described as the process/product to use for cleaning the machine.
b. There have been no patients served that were known to have had communicable diseases, including, but not limited to: Hepatitis B and HIV.

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

1) Ensure Psychosocial assessments are completed for two (2) (A1 & A2) of two (2) active sample patients. This failure results in treatment team's lack of ability to establish appropriate Master Treatment Plan (MTP) and Discharge planning. (B108)

2) Ensure the Psychiatric Evaluations for one (1) (A2) of two (2) active sample patients contain appropriate Psychiatric Diagnosis (B110). This failure leads to lack of appropriate patient information to formulate appropriate treatment plan.

3) Ensure individualized and specific treatment modalities (A1 & A2) are listed in the MTP (B122). This failure leads to lack of individualized, goal directed treatment.

4) Ensure that the Treatment Plans (A1 & A2) designate a specific staff to implement treatment modalities planned (B123). This hampers the facility's ability to hold staff accountable for essential treatment tasks besides diffusing staff members' sense of responsibility.

5) Ensure that all active therapeutic efforts (A1) are included in the MTP (B125). This could result in failure of staff to be aware of all of the identified patient problems to be addressed and stabilized prior to discharge.

6) Ensure that the nursing staff document patient's (A1 & A2) progress towards treatment goals accurately and completely (B127). This failure could result in lack of monitoring and evaluation of the treatment interventions.

Based on record review, policy review and staff interview complete social work assessments for two of two active sample patients (A1 & A2) were not in the record at the time of the record review on 06/26/2014. This resulted in an absence of professional social work evaluation and treatment services for two (2) of two (2) patients in the sample.

Findings include:

A. Record review:

1. Patient A1 was hospitalized on 06/21/2014. No psychosocial assessment was present in the record on 06/25/2014.

2. Patient A2 was hospitalized on 06/24/2014. No psychosocial assessment was present in the medical record as of 06/26/2014.

B. Policy review:

Policy "Job Description and performance evaluation" for Title: Inpatient Case Coordinator; Job Summary states "Ensure that the clinical record includes a comprehensive social history of the patient, focusing on issues that directly affect treatment on the unit and the development of a successful discharge plan". In the same policy, Section IV: Essential functions #6 states "Competent to complete psycho-social assessments".

C. Staff interview:

In a meeting on 06/25/2014 at 2:45 PM with the Director of Quality Improvement/Director of medical records regarding the absence of Psycho-social assessments stated, "No formal assessments are done".

Based on record review and staff interview it was determined that for one (1) (A2) of two (2) active sample patients, the Psychiatric Evaluation did not include a Psychiatric diagnosis. This failure results in a lack of necessary patient information for the treatment team to formulate an appropriate MTP.

Findings include:

Record review:

A. Patient A2 was hospitalized on 06/24/2014 and the Psychiatric Evaluation was completed on 06/25/2014 and this evaluation did not have any Psychiatric diagnosis listed.

Staff interview:

In a meeting with the Clinical Director at 1:00 PM on 06/26/2014, the Clinical Director acknowledged and agreed to the need for and lack of a Psychiatric diagnosis.

Based on record review and interview, the facility failed to consistently develop interventions on the Master Treatment Plans (MTPs) that included a focus for each intervention and/or frequency for two (2) of two (2) active sample patients (A1 & A2). The MTPs did not always include specific dates for expected achievements. In addition, the individual and group therapy intervention noted in the MTPs did not state a specific purpose and focus for two (2) of two (2) active sample patients (A1 & A2). The listed interventions were repetitive (similar for both patients) and were routine generic discipline functions instead of individualized interventions for patients. These deficiencies result from a lack of guidance for staff in providing individualized patient treatment that is purposeful and goal-directed.

Findings include:

A. Record review:

1. Patient A1 (MTP dated 6/22/2014):

For the problem of "Suicidal Ideation", the psychiatrist interventions were "Order precautions", "Evaluate and order medications as needed", and "Education regarding disease process." The nursing interventions were "Contract for safety", "Monitor patient per precaution protocol", "Administer medications as ordered", and "Education regarding disease process." The social work (In Patient Unit (IPU) case coordinator) interventions were "Contract for safety", "Individual and group therapy", "Education regarding disease process", and "Collateral contacts." For the problem of "Medical disease processes", the psychiatrist intervention was "Order Accucheck monitoring and insulin regimen", and "Order respiratory medications." The nursing intervention was "Provide protein snack", "Administer Accuchecks as ordered", "Monitor diet, exercise activity and general health", and "Administer medications as ordered." These interventions are generic, disciplinary functions, not individualized interventions based on the patient's needs.

2. Patient A2 (MTP dated 6/24/2014):

For the problem of "Patient is suicidal", the psychiatrist interventions were "Place on precaution", and "Medication regime." The nursing interventions were to "Monitor precautions", "Assess level of depression", "Individual and group sessions", and "Medication education." The social work interventions were "Individual and Group sessions" and "Collateral contacts." For the problem of "Ability to attend care concerns", the psychiatrist intervention was "Inter-disciplinary." The nursing intervention was "Inter-disciplinary." The social work intervention was "Inter-disciplinary." For the problem of "Community entitlement", the psychiatrist intervention was "Medicaid application." The nursing staff intervention was "Medicaid application." The social work intervention was "Medicaid application." For the problem of "Housing insecurity", the psychiatrist intervention was "Locating family and friends." The nursing intervention was "Locating family and friends." The social work intervention was "Locating family and friends." Some of the interventions listed were out of the scope of practice for the psychiatrist and nursing staff.

B Staff interview:

1. In an interview on 6/25/2014 at 3:45p.m with the charge nurse (N1), the charge nurse agreed that the interventions listed were indeed disciplinary routine expectations. She stated, "I see what you are getting at"!

Based on record review and interview, the facility failed to identify in the Master Treatment Plan (MTP) the specific team members by their full name and discipline who would each be held responsible for seeing that each intervention was carried out. The MTP reflected only the discipline responsible for two (2) of two (2) active sample patients (A1 and A2). This failure of not properly identifying the staff can result in confusion in deciphering who is primarily responsible for ensuring compliance with particular aspects of the patient's individualized treatment program.

Findings include:

A. Record review:

1. The facility's Policy and Procedure titled "Treatment Plans", updated 04/11/2014, failed to include detailed expectations regarding the quality of interventions to be used in developing the MTP. Instead, the policy states under the Procedure section, "The team decides what problems will be addressed while on the unit; establish long and short term goals, develop measurable objectives and interventions, document frequency, duration, etc. Assignment of responsibility will also occur at that time."

This policy failed to include the name and discipline requirement as outlined in the "Interpretive Guidelines for Psychiatric Hospitals." The guidelines state, "Identification of the staff should be recorded in a manner that includes the name and discipline of the individual."

2. Review of MTP two (2) of two (2) active sample patients (MTPs date in parenthesis); A1 (6/25/2014) and A2 (6/26/2014), showed only the discipline documented on the MTPs as responsible. Examples are as follows: "IPU case coordinator (social work)/nursing staff", "Provider", and "Nursing staff."

B Interview:

In an interview on 6/26/2014 at 9:15 PM, the Director of Nursing (DON) states, "I absolutely agree that it needs to be clearer, and we need to include the staff responsible."

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

The physician did not identify medical problems in the Master Treatment Plan (MTP) for one (1) of two (2) active sample patients (A1). This could result in the failure of staff to be aware of the medical problems to be addressed and may compromise patient's medical status and pose a health risk for the patient.

Findings include:

A Record review:

1. Patient A1 was admitted on 6/22/2014 for psychiatric treatment. During the patient's admission, his/her blood pressure became "Extremely elevated" and patient was sent to Marion General Hospital, where the patient was stabilized and returned. Upon return to the unit, his/her blood pressure was 177/106. Medical diagnoses were as follows: Hypertension, Hyperlipidemia, Chronic Obstructive Pulmonary Disease and Diabetes.

2. Review of the MTP 6/25/2014, "Medical diseases process" was identified as her problem with a description of "Diabetic and Asthma patient." The intervention identified for this problem was "Order Accucheck monitoring and insulin regime." There was no mention of the patient's other medical problems or treatment(s). Patient has been receiving medications for his/her Hypertension, Hyperlipidemia, Diabetes and Chronic Obstructive Pulmonary Disease.

B Interview:

In a meeting with the Medical Director on 6/26/2014 at 1:00 PM, the director stated, "I agree with the comments."

Based on policy review, record review and interview, the facility failed to ensure that nursing staff provide documentation of progress or lack of progress in accomplishing the goals outlined in the Master Treatment Plans (MTPs) for two (2) of two (2) active sample patients (A1 & A2). Failure to document the patient's progress toward goals identified in the MTP resulted in an absence of assessment and monitoring of patient response to interventions.

Findings include:

A Policy review:

1. The facility's policy titled "Nursing Standards for General Patient Care," dated 2/05/2014, states under Standard #6 "Nursing staff will assess the response of the patient to nursing care interventions on a daily basis. An entry describing the patient's status will be entered in the pink progress notes of the patients chart each shift by a registered nurse, licensed practical nurse or psychiatric technician under the supervision of the registered nurse." This statement is no longer applicable as the patient's records are now electronic.

The facility's policy titled "Treatment Plans" under Purpose (last paragraph) "Progress notes should reflect progress in accomplishing goals and the treatment plan can be updated and modified as needed throughout the inpatient stay."

Record review:

1. The nursing progress notes for two (2) of two (2) active sample patients (A1 & A2) did not address the goals of the MTP, nor did they document how the patient is responding to treatment and progressing towards the MTP goals.

2. Patient A1 (MTP 6/22/2014) Goal #1: "Safe on IPU (in patient unit) while resolving crisis." Goal #2: "Disease processes will remain stable while on IPU."

A review of nursing progress notes revealed the following documentations:

6/25/2014; Goal #1 "Monitor patient per precaution protocol."

6/25/2014; Goal #2 No documentation.

6/24/2014; Goal #1 "Patient continues to be monitored closely by inpt (in patient) staff for safety."

6/24/2014; Goal #2 No documentation.

6/23/2014; Goal #1 "Monitor patient per precaution protocol."

6/23/2014; Goal #2 No documentation

6/22/2014; Goal #1 "Monitor patient per precaution protocol."

6/22/2014; Goal #1 No documentation.

4. Patient A2 (MTP 6/24/2014) Goal #1: "Patient will be safe while on unit." Goal #2: "Patient will comply with care on the in-patient to stabilize mood, so that patient's insight and judgment would resolve to a level that would allow patient to attend other services needed."

5. A review of nursing progress notes revealed the following documentations:

6/24/2014; Goal #1 "Monitored per protocol."

6/24/2014; Goal #2 No documentation.

6/25/2014; Goal #1 "Patient continues to be monitored."

6/25/2014; Goal #2 No documentation.

B Interview

In an interview on 6/26/2014 at 9:15 PM with the Director of Nursing (DON) agreed that "there is a need to have a better method of addressing the progress of the patients."

The Clinical Director Failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically the Clinical Director failed to ensure that:

A. The Psycho-social assessments are completed for active sample patients A1 & A2. (Refer to B108)

B. The Psychiatric Evaluations (A2) contains a Psychiatric diagnosis. (Refer to B110)

C. The Master Treatment Plans (A1 & A2) list individualized specific treatment modalities. (Refer to B122)

D. The specific staff (A1&2) are designated to carry out specific treatment modalities. (Refer to B123)

E. All active therapeutic efforts (A1) are included in the MTP. (Refer to B125)

In an interview with the Clinical Director on 6/26/2014 at 1:00 PM, the clinical director stated "Agree with the comments."

Based on record review and interview, the Director of Nursing (DON) failed to monitor the quality and appropriateness of the nursing interventions found in the Master Treatment Plans (MTPs) of two (2) of two (2) active sample patients (A1 & A2). Instead, most of the interventions were routine, generic discipline functions inappropriately listed as individualized interventions. This deficiency results in lack of guidance for staff in providing individualized treatment with consistency of approach to each patient's problem.

A. Record Review:

1. Facility policy titled "Treatment Plans" updated 4/11, failed to include quality and expectations of interventions to be used in MTPs. The policy states, "The nursing assessment is completed at the time of admission...The initial treatment plan is started at that time." There was no mention of interventions specifically related to a patient's problems and needs.

2. The following generic nursing intervention in the MTP for two (2) of two (2) active sample patient A1 (MTP dated 6/22/2014), and A2 (MTP dated 6/24/2014). Nursing staff "Administer medication as ordered."

B. Staff Interview:

In an interview on 6/26/2014 at 09:15 PM, the generic nursing interventions on the MTPs were discussed with the Nursing Director. She stated, "I see what you mean, you are absolutely correct"!

Based on policy review, staff interview and record review the Director of Social Services failed to assure that the social work staff completes comprehensive Psycho-social assessments (A1 & A2) as per hospital policy in a timely manner. This failure affects the formulation of an appropriate master treatment plan and further it is not in accordance with the accepted standards of practice and established policies and procedures.

A. Record review:

As of 06/26/2014, patient medical records (A1 admitted on 6/21/2014, and A2 admitted on 6/24/2014) did not have Psycho-social assessments completed.

B. Policy review:

Job description for "Inpatient Case Coordinator" states, that staff must be "competent to perform Psycho-social assessments", and "staff must ensure that the clinical record includes a comprehensive social history...."

C. Staff interview:

In a meeting with the Director of Quality improvement/Medical Records Director on 06/25/2014 at 2:45 PM regarding the absence of psychosocial assessments stated "No formal assessments are done."