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Based on record review and staff interview, the facility failed to assess patient intellectual functioning, memory and orientation for 3 of 8 sample patients (A5, A7 and A15). This deficiency makes it impossible to follow the improvements of these parameters and adjust medications accordingly.

Findings include:

A. Record Review

1. The psychiatric evaluation for patient A5 (6/7/10) had no assessment of patient's memory.

2. The psychiatric evaluation for patient A7 (6/9/10) had no intellectual functioning, memory or orientation described.

3. The psychiatric evaluation for patient A15 (6/3/10) had no assessment of patient's memory.

B. Interviews

1. In an interview on 6/15/10 at 9:00 a.m. the CEO/Executive Director agreed that there was no testing of patients' memory for the 3 sample patients.

2. In an interview on 6/16/10 at 9:30 a.m. the Medical Director acknowledged the findings.

Based on record review and staff interview, the facility failed to include an inventory of patients' strengths in the admission psychiatric evaluations for 2 of 8 sample patients (A5 and A9). The failure to identify patient strengths impaired the treatment team's ability to choose treatment modalities which best utilized the patient's attributes in therapy.

Findings include:

A. Record Review

1. The psychiatric evaluation for patient A5 (6/7/10) had no strengths listed.

2. The psychiatric evaluation for patient A9 (6/5/10) had no strengths listed.

B. Interviews

1. In an interview on 6/15/10 at 9:00 a.m. the CEO/Executive Director agreed that patients' strengths were not listed for the two sample patients.

2. In the interview on 6/15/10 at 9:30 a.m. the Medical Director agreed with the findings.

Based on record review, interview and observation, the facility failed to document active treatment measures for 8 of 8 patients (A1, A5, A6, A7, A9, A10, A14 and A15) on the weekends and the evenings. The facility's failure to document active treatment on the weekends and the evenings potentially impaired the patients' attainment of treatment goals, and may have prolonged their hospitalization.

Findings include:

A. Record Review

1. Patient A10: admitted on 5/5/10 with a diagnosis of Major Depression, Recurrent. The "weekly patient group participation record" dated 5/3/10-5/9/10 had no documented groups occurring on the 3-11 p.m. shift for 5/6/10 and 5/7/10; and only morning community meeting and evening community wrap up groups were documented as occurring on the weekend of 5/8/10 and 5/9/10. The "weekly patient group participation record" dated 5/10/10-5/16/10 had no documented evidence of groups occurring on the 3-11 shift Monday through Friday and no evidence of groups other than the morning community meeting and evening community meeting occurring on the weekend. The "weekly patient group participation record" dated 5/17/10-5/23/10 had documented evidence that one evening community meeting occurred on the 3-11 shift on 5/21/10; weekend documentation revealed only morning and evening community meetings as occurring. The "weekly patient group participation record" dated 5/24/10-5/30/10 reflected only morning and evening community meetings occurring on the weekend. The "weekly patient group participation record" dated 5/31/10-6/6/10 had documented evidence of evening community meetings held on 5/31/10 and 6/4/10. The weekend of 6/5/10 and 6/6/10 had only morning and evening community meetings documented as occurring. The "weekly group participation record" dated 6/7/10-6/13/10 had no documented evening groups as occurring and only morning and evening community meetings as occurring on both weekend days 6/12/10 and 6/13/10. The group schedule reflects the following groups/activities are to be scheduled to occur on the 3-11 shift Monday-Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The Weekend (Saturday and Sunday) schedule reflects the following groups/activities are to be scheduled to occur: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

2. Patient A6: admitted 5/7/10 with a diagnosis of Schizoaffective Disorder. The "weekly patient group participation record" dated 5/3/10-5/9/10 had documented evidence of only morning and evening community meetings occurring on 5/8/10 and 5/9/10; the "weekly patient group participation record" dated 5/10/10-5/16/10 had no evidence of evening groups/activities occurring per program schedule and only morning and evening community meetings on the weekend of 5/15/10 and 5/16/10. Documentation was the same for the week of 5/17/10-5/23/10 with one exception -- an evening community meeting occurring on 5/21/10. The "weekly patient group participation record" dated 5/24/10-5/30/10 documented only two evening community meetings during the week (on 5/27/10 and 5/28/10); weekend documentation for 5/29/10 and 5/30/10 only showed a morning and evening community meeting done per schedule on both of these days. The "weekly patient group participation record" dated 5/31/10-6/6/10 and 6/7/10-6/13/10 had no evidence of evening groups/activities; the weekend documentation for 6/5/10-6/6/10 and 6/12/10-6/13/10 only showed morning and evening community meetings occurring on the four separate weekend days. The group schedule reflected the following groups/activities scheduled to occur on the 3-11 shift Monday-Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The Weekend (Saturday and Sunday) schedule showed the following groups/activities scheduled to occur: AM Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

3. Patient A15: admitted 6/3/10 with a diagnosis of Bipolar Disorder/Alcohol Dependence. The "weekly patient group participation record" dated 5/31/10-6/6/10 had documented evidence of only one evening community meeting on 6/4/10 during this week time period and only morning and evening community meetings occurring on both 6/5/10 and 6/6/10. The "weekly patient group participation record" dated 6/7/10-6/13/10 had evidence of only one evening community meeting (occurring on 6/10/10) and only morning and evening community meetings on the both weekend days of 6/12/10-6/13/10. The group schedule showed the following groups/activities scheduled to occur on the 3-11 shift, Monday-Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The "weekend (Saturday and Sunday) schedule" showed the following groups/activities scheduled to occur: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

4. Patient A9: admitted 6/5/10 with diagnosis of Schizophrenia, Paranoid Type. The "weekly group participation record" dated 6/7/10-6/13/10 had no evening groups/activities documented as occurring per weekly schedule, and only had documented morning and evening community meetings on both 6/12/10 and 6/13/10. The group schedule showed the following groups/activities scheduled to occur on the 3-11 shift, Monday: Friday-Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The Weekend (Saturday and Sunday) schedule showed the following groups/activities: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA(if applicable) at 8:00 PM.

5. Patient A5: admitted 6/7/10 with diagnosis Major Depressive Disorder/Poly-substance Abuse. The "weekly group participation record" dated 6/7/10-6/13/10 had no documented evening groups/activities as occurring and only had documented morning and evening community meetings for both 6/12/10 and 6/13/10. The group schedule reflected the following groups/activities scheduled to occur on the 3-11 shift, Monday: Friday-Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The Weekend (Saturday and Sunday) schedule showed the following groups/activities: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA(if applicable) at 8:00 PM.

6. Patient A7: admitted 6/9/10 with diagnosis Depressive Disorder NOS/Alcohol Dependence. The "weekly group participation record" dated 6/7/10-6/13/10 had one evening community meeting documented as occurring on 6/11/10 and morning and evening community meetings only occurring on both weekend days of 6/12/10 and 6/13/10. The group schedule reflected the following groups/activities scheduled to occur on the 3-11 shift, Monday- Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The weekend (Saturday and Sunday) schedule showed the following groups/activities scheduled to occur: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

7. Patient A14: admitted 6/11/10 with diagnosis Bipolar Disorder/Poly-substance Abuse. The "weekly patient group participation record" dated 6/7/10-6/13/10 had evidence of only morning and evening community meeting documented as occurring on both 6/12/10 and 6/13/10. The group schedule reflected the following groups/activities scheduled to occur on the 3-11 shift Monday- Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The weekend (Saturday and Sunday) schedule showed the following groups/activities scheduled to occur: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

8. Patient A1: admitted 6/12/10 with diagnosis Schizophrenia/PTSD/Alcohol Abuse. The "weekly patient group participation record" dated 6/7/10-6/13/10 had evidence of only morning and evening community meetings documented as occurring on both 6/12/10 and 6/13/10. The group schedule reflected the following groups/activities scheduled to occur on the 3-11 shift Monday- Friday: Arts and Crafts/Creative Expression at 4:00 PM; Community meeting at 6:30 PM; Coping Skills Group at 7:00 PM (Monday, Wednesday and Friday) and Leisure Activity at 8:00 PM. The weekend (Saturday and Sunday) schedule showed the following groups/activities are to be scheduled to occur: Morning Community Meeting; Coping Skills/Weekend Program at 10:15 AM; Leisure Activity at 11:15 AM; Group Activity/Weekend Program at 1:15 PM; Creative Expression at 4:00 PM; Leisure Activity at 6:30 PM; Wellness Group at 7:00 PM and Community Meeting/AA/NA (if applicable) at 8:00 PM.

B. Interview

1. During an interview with patients A14 and A1 on 6/14/10 at 11:10 AM in the lounge area, both reported being new admissions from the weekend and as a result not knowing what groups they are to attend. When the surveyor showed the patients the typed program schedule provided to the surveyor in the morning of the first day of the survey, both patients stated they had not received a copy of the schedule at the time of admission and did not know where on the unit to locate the day's schedule of groups/activities. Patient A14 walked down the corridor with the surveyor to locate the board of daily groups/activities and verified that the information on the board at the time of this tour was not present in the morning when he woke up, nor was anything documented on the board for the weekend. Patient A14 also stated "I was admitted over the weekend so you know weekend staff does not know what goes on during the week to tell me which groups I should be attending."

2. During an interview at 9:35 AM on 6/15/10 with the CEO/Executive Director, he verified that documentation in patients A10 and A9 records demonstrated that staff did not document that groups were done as scheduled on the evening and weekend hours as outlined on the facility program schedule, received by the surveyor by the Executive Director on 6/14/10 at 9:58 AM.

3. During an interview on 6/15/10 at 2:20 PM, the DON reported that she is responsible for the activities program and staff. "The psycho-educational groups/activities that are done by the nurses and the mental health technicians/counselors report directly to nursing. Each shift, 7-3 and 3-11 the groups are to be assigned by the nurse in charge. It is this person's responsibility to oversee that the scheduled groups/activities occur as outlined on the schedule." The DON validated that for 8 of 8 patients (A10, A6, A15, A9, A5, A7, A14 and A1); documentation of the "weekly patient group participation record" was either inconsistent or not done to verify that groups scheduled on the pre-printed program schedule occurred as planned. She further validated that there currently is "no quality monitoring in place to evaluate the effectiveness of group programming and/or whether or not patients' attend groups as outlined in their treatment plan."

C. Observation

1. On 6/15/10, at 9:15 AM, the surveyors noted that the daily group/activities board posted in the main corridor of the unit had not been updated with the schedule of events for the day. The last update to the board was for the day light shift for 6/14/10; no updates for groups/activities scheduled to be done on the 3-11 shift on 6/14/10 were noted.

2. During the interview with the DON on 6/15/10, observations were conducted at 2:45 PM to validate when information is to be updated on the daily board. The DON stated that "the weekly schedule is to be posted and maintained on the grey board outside of the nurse's station, and the mental health technician is responsible for writing the date and the days' activities on the white board daily after report." The DON acknowledged that there was not a weekly schedule posted as required for patient reference.

Based on observation, record review and interview, the Medical Director failed to adequately ensure the quality and appropriateness of services provided by the medical staff. Specifically, the Medical Director failed to:

I. Ensure that patient intellectual functioning, memory and orientation were assessed for 3 of 8 sample patients (A5, A7 and A15). This deficiency makes it impossible to follow the improvements of these parameters and adjust medications accordingly. (Refer to B116)

II. Ensure that an inventory of patients' strengths was included in the psychiatric evaluations for 2 of 8 sample patients (A5 and A9). The failure to identify patient strengths impaired the treatment team's ability to choose treatment modalities which best utilized the patient's attributes in therapy. (Refer to B117)

III. Ensure that active treatment measures were documented for 8 of 8 sample patients on the evenings and weekends. The facility's failure to document active treatment on the weekends and the evenings potentially impaired the patients' attainment of treatment goals, and may have prolonged their hospitalization. (Refer to B125)

Based on record review and interview, the Director of Nursing failed to:

I. Ensure that active treatment measures were documented for 8 of 8 sample patients on the evenings and weekends. The facility's failure to document active treatment on the weekends and evenings potentially impaired the patients' attainment of treatment goals, and may have prolonged their hospitalization. (Refer to B125)