The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PUTNAM COUNTY MEMORIAL HOSPITAL 1926 OAK STREET, PO BOX 389 UNIONVILLE, MO 63565 May 14, 2015
VIOLATION: ACTIVITIES STAFF Tag No: C0596
Based on observation, interview and record review the facility failed to ensure the Behavioral Health Unit (BHU) Activities were directed by a staff member qualified by training and/or education to provide therapeutic activities to this unit. The failure to ensure a qualified activities director for the unit had the potential to prohibit those patients from achieving their maximum potential outcomes through appropriate and individualized therapeutic activities. The facility census was 10. The BHU census was five.

Findings included:

1. Record review of the facility's BHU job description titled, "Director of Activities/Assistant to Social Worker", dated 03/2014, showed the minimum qualification for the position was a Bachelor's Degree and/or State activities certificate.

2. During an interview on 05/13/15 at 10:30 AM, Staff D, Registered Nurse (RN), BHU Lead RN, stated that the current activities director for the BHU was Staff H, Licensed Practical Nurse (LPN). She stated that Staff H had not been certified in activities and there had been no plan developed for her to become certified.

During an interview on 05/14/15 at 9:15 AM, Staff H, LPN, stated that she was responsible for maintaining the activities program for the BHU. She stated that:
- She was one of a group that came together to plan a weekly activities calendar.
- The group consisted of a Certified Nursing Assistant (CNA), herself and the intake counselor;
- Her previous experience in activities had been to fill in and help with activities for long term care residents in a nursing home.
- She was not certified in activities and there had been no plan developed for her to become certified.

During an interview and concurrent record review of the personnel file for Staff H on 05/14/15 at 3:00 PM, Staff C, Human Resources (HR) Director, stated that she was aware the Director of Activities for the BHU did not have a Bachelor's degree or State activities certification. She stated that there had been no plan developed for Staff H to become certified.