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.

WELLSTONE REGIONAL HOSPITAL 2700 VISSING PARK RD JEFFERSONVILLE, IN 47130 Dec. 8, 2017
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on document review and interview, the hospital failed to review and resolve 1 grievance in 1 instance.

Findings include:

1. Review of the policy titled Patient Advocacy Program, Review/Revision Date: 6/16, indicated the following:
A. 3.0 Department Manager will be responsible for the following: 3.1 Discuss grievance with patient, family/guardians, and other as deemed appropriate. 3.2 Investigates concerns, takes actions and provides mediation toward problem resolution. 3.3 Documents all investigation information and action taken. 3.4 Forwards all Patient Advocate forms to Patient Advocate Representative within one working day.
B. 4.0 Patient Advocate and Representative will be responsible for the following: 4.1 Review all concerns/issues, actions taken and pursues further resolution if deemed appropriate. 4.2 Assist patient and other concerned individuals to pursue process through all levels until problem resolution. 4.3b. Gives written documentation of process to patient, family/guardian. 4.6 Will complete the following for patients who have been discharged . a. Will discuss grievance with patient, family/guardian... b. Investigates concerns, takes action, and provides mediation toward problems resolution. c. Documents all investigation information and action taken.

2. On 12/7/17 at approximately 11:30am A2, Director of Nursing (DON), indicated that a parent of patient P2 called with a complaint of the physician stopping a medication and complained believed patient lab values were low and not being checked. A2 indicated that the patient did not have a patient advocate. Indicated that if a call comes in after discharge then the complaint goes to the patient advocate and is discussed. A2 indicated uncertainty of when the call came in or to whom.

3. On 12/7/17 at approximately 1:00pm A4, Manager of Youth Services, indicated he/she became involved with the parent of P2 after reviewing a report noting concern of P2's physical condition and making contact to the parent. A4 indicated that the parent voiced concerns/complaints about P2 being previously discharged from PHP (partial hospital program) without an order for Klonopin and the current care P2 was receiving.

4. Review of hospital complaints and grievance logs between 6/1/17 and 12/7/17 lacked documentation of a complaint or grievance related to the complaint voiced by the parent of P2.

5. On 12/7/17 at approximately 4:00pm A7, Patient Advocate, indicated he/she had not received a complaint/grievance related to P2. A7 indicated concern forms are to be forwarded to him/her daily and that if a patient or guardian calls in, the call is forwarded to A7.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to ensure medical staff (MS) carried out responsibilities according to policies and the MS Rules and Regulations for 5 of 11 medical records reviewed (P1A, P1, P5, P6 and P7).

Findings include:

1. Review of hospital policies and MS Rules and Regulations indicated the following:
A. Policy titled Partial Hospital Program - Discharge Planning and Discharge, Revised 1/1/12: II. Policy: Discharge planning will be organized, coordinated process, with interdisciplinary treatment team, client, physician and family/significant other input. All anticipated discharges from the Program will be discussed with the physician and significant others involved in the client's care, before a discharge decision is made. III. Procedure: B. A plan of transition will be developed, which includes contacting the appropriate referral agency, establishing a time-line for discharge from the program, actively involving the client in the planning and a subsequent decrease in treatment days. C. The plan will be discussed and agreed upon with the client.
B. Policy titled Medication Reconciliation, Reviewed/Revision Date 6/17: Policy: (Hospital) will require the reconciliation of medication for patients in the PHP at discharge. WHO: DOES WHAT: 9. Psychiatrist indicates discharge/transfer orders in HCS (computer system).
C. Policy title Interdisciplinary Treatment Plan, Reviewed/Revision Date 8/15: Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. This team shall consist of the: physician, nurse, therapist, a representative of specialized therapies, the patient and other disciplines as appropriate. Ultimate responsibility for the development and implementation of the treatment plan shall rest with the physician.
D. Policy titled Partial Hospital Program - Progress Notes, Reviewed 3/13/17: II. Our Program is required...to document progress on a daily basis by intervention. III. Procedure: A. Daily Progress Notes/Master Treatment Plan Updates. c. Physicians should document client progress toward treatment goals, need for continued treatment and discharge readiness.
E. Medical Staff Rules and Regulations, Reviewed/Revised 11/17/16: 2.1 Residential Treatment Program for Children and Adolescents (RTPCA). 2.11.7 The attending physician will complete a dictated discharge summary within 15 days of the patient's discharge... 3. Care and Treatment of Patients. 3.4 The attending physician shall be present at treatment team meetings on all patients and shall participate in, review, and approve all treatment plans formulated by the treatment team. 5.6 Progress Notes 5.6.4 Attending Members shall document: g. discharge plan; h. response to Medication and Treatment Interventions; and i. justification for changes to the patient's medication. 5.8 Discharge Documentation 5.8.4 The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare... 5.9 Completion of Medical Records 5.9.1 All discharge summaries and other MR documentation shall be completed within 30 days following the patient's discharge.

2. Review of the MRs indicated the following:
A. The MR of P1A indicated the patient, an adolescent, was admitted to the PHP (partial hospital program) 10/26/17 and discharged [DATE] per face sheet (conflicting dates in MR), the Clinical Discharge Summary indicated discharge date as 11/22/17. The Comprehensive Psychiatric Evaluation, Date of Evaluation 10/26/17, lacked documentation of an established time-line for discharge. Admission Orders dated 10/26/17 indicated the following: Attend 5 days per week, with an estimated length of stay in treatment of _______ weeks. The blank lacked documentation of an established time-line for discharge. The MR lacked documentation of discharge planning coordinated with interdisciplinary treatment team that included the physician. The MR lacked documentation of the physician attending treatment team meetings or participating in review and approval of treatment plan(s). Physician Progress Note dated 11/6/17 lacked documentation of the patient's progress toward treatment goals or discharge readiness. The MR lacked documentation of psychiatrist discharge orders with Medication Reconciliation entered into the computer system. The MR lacked documentation of a physician dictated discharge summary.
B. The MR of P1 an adolescent, was admitted [DATE] at 07:54 hours for Major Depressive Disorder and a Provisional Medical Diagnosis of bulimia, was transferred to another facility 11/27/17 and was discharged [DATE] at 20:00 hours. The Interdisciplinary Master Treatment Plan (MTP), Date of Admission, lacked documentation of psychiatrist. The MR lacked documentation of the physician attending treatment team meetings or participating in review and approval of treatment plan(s). The MR lacked documentation of psychiatrist discharge orders with Medication Reconciliation entered into the computer system.
C. The MR of patient P5, a geriatric patient, indicated the patient was admitted [DATE] at 22:48 hours for Major Depressive Disorder with a secondary diagnosis of anorexia and was discharged [DATE] at 12:10 hours. The Interdisciplinary Master Treatment Plan dated 11/7/17 lacked documentation of involvement of the Psychiatrist. The Interdisciplinary Master Treatment Plan Update/Revision dated 11/13/17 also lacked documentation of involvement of the psychiatrist. The MR lacked documentation of a physician dictated discharge summary.
D. The MR of patient P6, a geriatric patient, indicated the patient was admitted [DATE] at 19:15 hours for Alzheimer's disease with a secondary diagnosis of anorexia and was discharged [DATE] at 11:00 hours. The Interdisciplinary Master Treatment Plan dated 11/17/17 lacked documentation of involvement of the Psychiatrist.
E. The MR of patient P7, a geriatric patient, indicated the patient was admitted [DATE] at 15:24 hours for Unspecified dementia with secondary diagnosis of anorexia and was discharged [DATE] at 09:00 hours. The Interdisciplinary Master Treatment Plan dated 10/23/17 lacked documentation of involvement of the Psychiatrist. The Interdisciplinary Master Treatment Plan Update/Revision(s) dated as follows lacked documentation of involvement of the Psychiatrist: 10/30/17, 11/6/17, 11/14/17 and 11/21/17.

3. On 12/8/17 at approximately 2:30pm, during MR review, A2, Director of Nursing, verified lack of MR documentation for discharge planning, physician order/computer entry and medication reconciliation and physician involvement in MTPs.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, nursing staff failed to supervise and evaluate care for 10 of 10 (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) patients to assure care was provided in accordance with hospital policy.

Findings include:

1. Review of hospital policies indicated the following:
A. The policy titled Eating Disorders, Reviewed/Revision Date 8/16, indicated the following: It is the policy of (The Hospital) to appropriately assess individuals with eating disorders and to monitor weight and food-related behaviors. 3. Nursing staff will monitor and record patient's weight at admission and weekly unless a different frequency is ordered by the physician. 5. Food intake and food-related behaviors will be monitored and recorded for all meals and snacks. 6. Patients may be placed on one to one observation for one hour after meals and snacks as prescribed by the physician.
i. Review of the attached document titled Bulimia Protocol indicated the following: It is the practice of (The Hospital) to monitor patient closely who have been identified as having behaviors associated with bulimia such as gorging and purging. Patients identified will be monitored as follows: 1. Food intake will be monitored and recorded for all meals and snacks. 4. Staff will accompany and monitor any patient on constant Line of Sight for one hour after meals and snacks. Staff will distribute an assignment to be completed during the one hour monitoring period as determined by his/her therapist.
B. The policy titled Vital Signs, Reviewed/Revision Date 3/17, indicated the following: All patients admitted to (The Hospital) will have vital signs (vs) taken on admission; three times a day for geriatric patients; twice daily for adult, adolescent and children psychiatric units; and every two hours while awake for 72 hours, then every 4 hours while awake for adult chemical dependency patients. Vital signs will include temperature, pulse, respirations and blood pressure. 13.0 - Document all vs in the patient's medical record.
C. The policy titled Medication Administration, Reviewed/Revision Date 6/17: 35.0 All medications are documented on the Medication Administration Record (MAR) immediately after they are given...The nurse is to initial the MAR when dispensing medications and sign complete name and credentials on each patient's signature page kept with the patient's MAR. 40.0 If a new medication is ordered and needed prior to the next pharmacy delivery, the nurse is to call the Pharmacy, when open, to notify them of the order and request that the order be delivered as soon as possible. If the Pharmacy is closed, the nurse is to notify the House Supervisor, who will obtain the medication from the Night Cabinet. If the medication cannot be obtained within the hospital, the House Supervisor will assist in obtaining the medication. 41.0 If for some reason a medication has not been delivered from the pharmacy or is not available, the physician is notified immediately.

2. Review of patient MRs indicated the following:
A. Patient P1A indicated the patient, an adolescent, was admitted to the PHP (partial hospital program) 10/26/17 and discharged [DATE] per face sheet (conflicting dates in MR). The Medical Social Worker Clinical Discharge Summary indicated the patient was discharged [DATE]. The MR MAR (medication administration record) indicated the following: Month: October. Year: 2017. Medication: Klonopin 1mg (give noon) Frequency: tid. Number/day 26 was initialed and number/days 27 and 30 were initialed with 12:00 hours indicated. Hand written below was the following: given 11/2/17 with initials. Month: November. Year: 2017. Medication: Klonopin 1mg PO. Frequency: at noon. The following days were initialed: 1, 6, 7, 8, 9, 10, 13, 14, 15, 16, and 17. The MR lacked documentation of other days of medication administration or reason not given and lacked documentation of names with credentials.
B. Patient P1, an adolescent, was admitted [DATE] at 18:51 hours for Major Depressive Disorder and a Provisional Medical Diagnosis of bulimia, was transferred to another facility 11/27/17 and was discharged [DATE] at 20:00 hours. The nursing assessment dated [DATE] at 2200 hours indicated the following: Actual Weight: 100 lb (pounds). Physical Appearance: Under weight. Nutrition Screening: Purging after meals. The Initial Nursing Treatment Plan indicated the following: Reason for hospitalization : SI (suicidal ideation) and Bulimia. The Chronic/Stable Individual Treatment Plan indicated the following: 11/24/17 Short-Term Goals: Bulimia Imbalanced nutrition. Specific Intervention Focus: 2 hour meal precautions. Provide small meals and supplement snacks as appropriate. The MR Diet Intake log lacked documentation of food intake, am (breakfast), noon (lunch), pm (dinner), snack, as follows: On 11/24/17 pm or snack; on 11/26/17 am, noon, pm or snack; on 11/27/17 noon, pm or snack. Progress note dated 11/26/17 at 2350 hours indicated the patient consumed a supplement drink and snack, was monitored for 2 hours for meal precautions and had 0 episodes of purging following the consumption. Progress note dated 11/25/17 at 1859 hours indicated the patient reported throwing up blood and flushed it. The remaining Progress Notes dated 11/25/17 and 11/27/17 lacked documentation of diet or supplement intake and lacked further documentation of 2 hour meal precaution monitoring or food-related behaviors. Physician orders dated 11/24/17 indicated VS were to be obtained at admission and then BID (2x per day). The MR lacked documentation of VS obtained BID on 11/24/17, 11/25/17, 11/26/17 or 11/27/17. MAR (medication administration record) documentation indicated the following were ordered, scheduled to be given and not administered as ordered as follows: 11/25/17 Klonopin 1mg TID, scheduled 08:00 hours - Not Administered. Drug not available. 11/25/17 09:00 hours - Not Administered. Drug not available. (The MAR indicated 11/25/17 11:54 hours Klonopin 1mg, One Time Administration. Administered 11:55 hours). 11/25/17 Klonopin 1mg TID, scheduled 16:00, 21:00 and 09:00 hours; not administered 11/27/17 16:33 hours - Patient not available. 11/27/17 Ensure 1 each TID, scheduled 09:00 and 16:00 hours. The MR lacked documentation of nursing calling the pharmacy, notifying House Supervisor or notifying the physician of medications not available.
C. Patient P2, an adolescent, was admitted [DATE] at 23:52 hours for Major Depressive Disorder with a secondary diagnosis of an eating disorder, NOS (not otherwise specified) and was discharged [DATE] at 11:00 hours. The Initial Nursing Treatment Plan, not dated, indicated Reason for hospitalization : History of Eating Disorder. Physician orders dated 10/5/17 indicated meal precautions were to be implemented. Nursing note documentation dated 10/5/17 indicated the patient was to be on 2 hour meal precautions. The MR lacked documentation of 2 hour meal precautions, food-related behaviors or recorded food intake for 10/3/17 am, noon, pm or snack; 10/4/17 pm or snack; 10/5/17 noon, pm or snack; 10/6/17 noon, pm or snack and 10/7/17 am or snack. The MR lacked documentation of VS obtained BID on 10/3/17, 10/6/17 and 10/7/17.
D. Patient P3, an adult, was admitted [DATE] at 21:55 hours for Major Depressive Disorder with a secondary diagnosis of an eating disorder and was discharged [DATE] at 17:00 hours. The Medical Consult/H&P Brief Note indicated "Binges". The MR lacked documentation of recorded food intake for 9/27/17 pm or snack; 10/4/17 pm or snack; 9/28/17 pm or snack; 9/30/17 pm or snack; and 10/1/17 pm or snack. The MR lacked documentation of VS obtained BID on 9/29/17 and 10/2/17.
E. Patient P4, an adult, was admitted [DATE] at 16:30 hours for Bipolar Disorder with a secondary diagnosis of bulimia nervosa and was discharged [DATE] at 13:37 hours. The Intake Assessment indicated patient had a history of purging. Physician orders dated 10/27/17 indicated VS upon Admission and then BID. The MR lacked documentation of after meal monitoring and lacked recorded food intake for 10/27/17 pm or snack; 10/28/17 pm or snack; 10/29/17 am, noon or snack The MR lacked documentation of VS obtained BID on 10/28/17. The MAR indicated the following were ordered, scheduled and not administered as per order as indicated: Ordered 10/28/17 Toprol-XL 50mg Once a Day; scheduled 10/28/17 09:00 hours, 11:02 hours Not Administered, Drug not available. Scheduled 10/29/17 09:00 hours, 08:54 hours Not Administered, Drug not available. Ordered 1/28/17 Cozaar 100mg Once a Day; scheduled 10/28/17 09:00 hours, 11:01 hours Not Administered, Drug not available. Ordered 10/28/17 Metformin tablet 500mg, scheduled 10/28/17 09:00 hours, 11:01 hours Not Administered, Drug not available. Ordered 10/29/17 Lexapro 10mg Once a Day, scheduled 09:00 hours, 09:49 hours Not Administered, Drug not available. The MR lacked documentation of nursing calling the pharmacy, notifying House Supervisor or notifying the physician of medications not available.
F. Patient P5, a geriatric patient, was admitted [DATE] at 22:48 hours for Major Depressive Disorder with a secondary diagnosis of anorexia and was discharged [DATE] at 12:10 hours. The MR lacked documentation of recorded food intake for 11/10/17 pm or snack.
G. Patient P6, a geriatric patient, was admitted [DATE] at 19:15 hours for Alzheimer's disease with a secondary diagnosis of anorexia and was discharged [DATE] at 11:00 hours. The MR lacked documentation of recorded food intake for 11/17/17 pm or snack and 11/21/17 noon or snack. The MR lacked documentation of VS obtained TID (3 x per day) on 11/20/17 or 11/26/17.
H. Patient P7, a geriatric patient, was admitted [DATE] at 15:24 hours for Unspecified dementia with secondary diagnosis of anorexia and was discharged [DATE] at 09:00 hours. The MR lacked documentation of recorded food intake for 10/23/17 pm or snack; 10/27/17 noon or snack; 10/31/17 pm or snack; 11/1/17 pm or snack; 11/10/17 pm or snack; 11/17/17 noon or snack. The MR lacked documentation of VS obtained TID on 10/30/17 or on 11/9/17.
I. Patient P8, a geriatric patient, was admitted [DATE] at 22:48 hours for Alzheimer's disease with a secondary diagnosis of anorexia and was discharged [DATE] at 16:30 hours. The MR lacked documentation of recorded food intake for 10/19/17 pm or snack.
J. Patient P9, a geriatric patient, was admitted [DATE] at 18:30 hours for Unspecified dementia with secondary diagnosis of anorexia and was discharged [DATE] at 13:33 hours. The MR lacked documentation of recorded food intake for 10/9/17 pm or snack; 10/12/17 am, noon or snack and pm was documented as "asleep"; 10/31/17 pm or snack; 11/1/17 pm or snack; 11/10/17 pm or snack; 11/17/17 noon or snack. The MR lacked documentation of VS obtained TID on 10/13/17.
K. Patient P10, a geriatric patient, was admitted [DATE] at 22:45 hours for Alzheimer's disease with a secondary diagnosis of anorexia and was discharged [DATE] at 15:30 hours. The MR lacked documentation of recorded food intake for 10/27/17 am or snack; 11/1/17 noon, pm or snack; 11/2/17 noon had 100% and was crossed out without explanation and 11/7/17 noon or snack. The MR lacked documentation of VS obtained TID on 10/30/17 or on 11/2/17 and only 1 x on 11/7/17.

3. On 12/8/17 between approximately 11:45am and 2:30pm A2, DON (Director of Nursing), verified lack of MR documentation for after meal monitoring of patients with bulimia, recorded food intake for patients with eating disorders and lack of VS per policy.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to ensure discharge planning assessed responsiveness to discharge needs in accordance with hospital policy for 1 of 1 Partial Hospital Program (PHP) patients (P1A) and 1 of 10 inpatients (P1).

Findings include:

1. Review of facility policies indicated the following:
A. Policy titled Partial Hospital Program - Discharge Planning and Discharge, Revised 1/1/12: II. Policy: Discharge planning will be organized, coordinated process, with interdisciplinary treatment team, client, physician and family/significant other input. The process identifies the client's needs before and after discharge, delineates plans to meet these needs and teaches the client and family how to implement the plans. Discharge planning will being on admission. Discharge criteria are tied to the long-term goals and will be established during the development of the Master Treatment Plan (MTP). All anticipated discharges from the Program will be discussed with the physician and significant others involved in the client's care, before a discharge decision is made. III. Procedure: B. A plan of transition will be developed, which includes contacting the appropriate referral agency, establishing a time-line for discharge from the program, actively involving the client in the planning and a subsequent decrease in treatment days. C. The plan will be discussed and agreed upon with the client.
B. Policy titled Partial Hospital Program - Treatment Planning, Reviewed 3/13/2017: II. Policy: A MTP will be established on the day of admission. III. Procedure: Step Three: Client Involvement - The primary Therapist should meet with the client to: 6. Discuss discharge planning based on recommended treatment goals. Guidelines For MTP Preparation: Steps to Presenting a MTP: Treatment plans should be presented at the treatment team meeting: The following is a recommended format to a thorough, organized, and timely presentation. 6. Present a tentative discharge plan and an estimated length of stay.
C. Policy titled Partial Hospital Program - Plan For Professional Services And Staff Composition, Reviewed 3/13/2017: XIII. Discharge Process: The client's discharge needs are identified on admission to the program. As the client's needs become more defined, programming for the client will be modified to meet those needs. When the client is discharged from the Program, the Primary Therapist will follow-up with the referral source and those in the community providing support...
D. Policy titled Partial Hospital Program - Patient/Family Involvement in Treatment, Reviewed 3/13/2017: I. Purpose: To encourage family members and/or significant others (to) become involved in the client's treatment. F. Discharge/aftercare plans are developed for each patient which take into account family perceptions and needs whenever possible.
E. Policy titled Medication Reconciliation, Reviewed/Revision Date 6/17: Policy: (Hospital) will require the reconciliation of medication for patients in the PHP at discharge. WHO: DOES WHAT: 9. Psychiatrist indicates discharge/transfer orders in HCS (computer system). Discharge Nurse: 10. Reviews the Discharge Medication Reconciliation Order form to ensure the accuracy of the discharge/transfer medications. 13. Provides instruction to the patient regarding their medications to be taken after discharge. 15. Places Discharge Medication Reconciliation form in the Discharge section of the record.
F. Policy title Interdisciplinary Treatment Plan, Reviewed/Revision Date 8/15: Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team. This team shall consist of the: physician, nurse, therapist, a representative of specialized therapies, the patient and other disciplines as appropriate. Ultimate responsibility for the development and implementation of the treatment plan shall rest with the physician.
G. Policy titled Partial Hospital Program - Progress Notes, Reviewed 3/13/17: II. Our Program is required...to document progress on a daily basis by intervention. III. Procedure: A. Daily Progress Notes/Master Treatment Plan Updates. c. Physicians should document client progress toward treatment goals, need for continued treatment and discharge readiness.
H. Medical Staff Rules and Regulations, Reviewed/Revised 11/17/16: 2.1 Residential Treatment Program for Children and Adolescents (RTPCA). 2.11.7 The attending physician will complete a dictated discharge summary within 15 days of the patient's discharge... 3. Care and Treatment of Patients. 3.3 Discharge criteria should be specified as soon as possible after admission, and discharge planning should begin at that time. Updates and changes in discharge criteria and discharge planning should be recorded as appropriate. 3.4 The attending physician shall be present at treatment team meetings on all patients and shall participate in, review, and approve all treatment plans formulated by the treatment team. 5.6 Progress Notes 5.6.4 Attending Members shall document: g. discharge plan; h. response to Medication and Treatment Interventions; and i. justification for changes to the patient's medication. 5.8 Discharge Documentation 5.8.4 The record of each discharged patient must include a discharge summary of the patient's hospitalization and recommendations concerning follow-up or aftercare... 5.9 Completion of Medical Records 5.9.1 All discharge summaries and other MR documentation shall be completed within 30 days following the patient's discharge.

2. Review of MRs indicated the following:
A. Review of the PHP MR of patient P1A indicated the patient, an adolescent, was admitted to the PHP (partial hospital program) 10/26/17 and discharged [DATE] per face sheet (conflicting dates in MR), the Clinical Discharge Summary indicated discharge date as 11/22/17. The Comprehensive Psychiatric Evaluation, Date of Evaluation 10/26/17, lacked documentation of an established time-line for discharge. Admission Orders dated 10/26/17 indicated the following: Attend 5 days per week, with an estimated length of stay in treatment of _______ weeks. The blank lacked documentation of an established time-line for discharge. The document titled Transition Record Checklist lacked a check (indication of documentation provided to patient at discharge) for Discharge Medication Reconciliation or Medication Education. The MR lacked documentation of discharge planning initiated on day or admission in coordination with interdisciplinary treatment team, client, physician and family. The MR lacked documentation of a MTP with anticipated discharge from the Program discussed with the physician and significant others prior to a discharge decision was made. The MR lacked documentation of the plan having been discussed with and agreed upon by the client. The MR lacked documentation of development and implementation of a plan of transition establishing a time-line for discharge from the program or actively involving the client in the planning and lacked documentation of subsequent decrease in treatment days. Progress notes lacked documentation of patient readiness for discharge. The MR lacked documentation of the Primary Therapist meeting with the client or family to discuss discharge planning. The MR lacked documentation of Primary Therapist follow-up with referral source(s). The MR lacked documentation of a Discharge Medication Reconciliation form.
B. Patient P1, an adolescent, was admitted [DATE] at 18:51 hours for Major Depressive Disorder and a Provisional Medical Diagnosis of bulimia, was transferred to another facility 11/27/17 and was discharged [DATE] at 20:00 hours. The Interdisciplinary Master Treatment, Date of Admission 11/24/17, signed by a nurse and an Activity Therapy Team Member, lacked signatures or documentation of participation by a Psychiatrist or Social Worker. The Plan lacked documentation or indication of patient participation. The Treatment Plan lacked documentation in indicated areas of Patient Strengths, Patient Limitations, Discharge Criteria and Initial Discharge Disposition. The MR lacked documentation of a physician discharge summary.

3. On 12/8/17 at approximately 2:30pm, during MR review, A2, Director of Nursing, verified lack of MR documentation for discharge planning, treatment plans and medication reconciliation.