HospitalInspections.org

Based on observations, records review, interviews and documents review, the facility was not primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5) and five (5) of the five (5) sample discharged patients (E1, E2, E3, E4, and E5).


The facility failed to:


I. Provide active psychiatric treatment for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5). These patients received primarily substance abuse treatment during their hospitalization. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physicians. No other interventions were specifically designed for the treatment of psychiatric conditions. Master Treatment Plans listed Problems and Goals that focused on substance abuse treatment. All group treatments were focused on chemical dependency treatment. The failure to identify psychiatric issues and provide treatment results in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital.


II. Ensure Master Treatment Plans listed Problems and Objectives (goals) with a primary focus on the treatment of mental illness. Eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5) were admitted for detoxification and recovery treatment for chemical dependency and the treatment plans focused primarily on detoxification and recovery treatment for chemical dependency. This results in patients receiving treatment which does not focus on psychiatric illness.


III. Ensure that a psychiatric evaluation documented contained sufficient information to justify psychiatric diagnoses and treatment for five (5) of eight (8) active sample patients (A3, A6, B1, C1, and D2) and that a completed psychiatric evaluation was completed for 1 of eight (8) active sample patients (B3). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan (MTP) for the treatment psychiatric illnesses.


IV. Complete a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the assessments and treatments provided for a psychiatric illness for five (5) out of five (5) discharged patients (E1, E2, E3, E4, and E5). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan for psychiatric illnesses with providers providing follow-up care.


Findings include:


I. Psychiatric Treatment


A. Observations and Interviews


1. During an observation of the "Rehab Group" conducted by SW 1 on 11/1714, at 11:00 a.m., SW 1 involved the patients in a discussion of an aspect of the "12-Step" program. No issues specifically regarding psychiatric illness were addressed during this group. During an interview with SW 2 on 11/17/14, at 11:40 a.m., he stated that the groups he conducted in the facility were focused on chemical dependency treatment.


2. During an observation of the "REC Therapy" group conducted by RT 1 on 11/17/14, at 2:00 p.m., the patients completed a worksheet identifying leisure activities and other "habits" they could develop during periods of sobriety. No issues specifically regarding psychiatric illness were addressed during this group. During an interview with RT 1 on 11/17/14, at 2:25 p.m., she reported that she conducted two groups per week. She stated that both groups were related to chemical dependency. She stated that one group was provided to assist patients to "learn outlets they can do when sober" and the other to improve their relationship with their "sponsor" after discharge.


3. During an observation of the "Dual Diagnosis" group conducted by Chemical Dependency Counselor 1 on 11/18/14, at 12:30 p.m., the group focused on recovery from chemical dependency. No issues specifically regarding psychiatric illness were addressed during this group.



B. Patient Interview

During an interview with Patient A1 on 11/17/14, at 1:30 p.m., s/he stated that s/he was admitted to the facility for "drinking too much...just the drinking. I don't have problems with my nerves."



C. Staff Interviews


1. During an interview with the Clinical Admissions Specialist on 11/18/14, at 12:05 p.m., she stated that facility accepted patients for admission using specific criteria documented on the "Admission Criteria - Adult Chemical Dependency" form including the following: "All of the following criteria must be met:" "the primary need for treatment is drug and/or alcohol dependency; a co-existing psychiatric condition may be present, but must not be the primary reason for admission."


2. During an interview with the Director of Nursing 11/18/14, at 1:15 p.m., he was unable to identify any psychiatric treatment being conducted by nursing staff other than medication administration. He stated that the psychiatric treatment was "not what it should be." He stated that the facility was "lacking in psychiatric treatment" by nursing staff and the facility "could do a better job."


3. During an interview with the Clinical Director on 11/17/14, at 2:40 p.m., she stated that the facility screened potential patients to ensure that they required primarily chemical dependency treatment. She stated "although we take some dual diagnosis [patients], if they are primarily psychiatric, we refer them to another psych [psychiatric] facility." She stated that the programming for the unit was designed for "the population [inpatient chemical dependency] we are working with." She estimated "85% [of the patients] require detox [detoxification], then step down to rehab." She stated that social work staff met with the patients but did not provide individual therapy. She stated "most of it [treatment] is group-based." During an interview with the Clinical Director on 11/18/14, at 3:50 p.m., she acknowledged that the facility was primarily engaged in chemical dependency treatment. She stated the facility was "not focused on primary psychiatric" treatment.


4. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he stated that the "whole thrust of all the groups" provided at the facility was "geared toward" chemical dependency treatment. He acknowledged that all groups were based in the 12 Step-Program. He estimated that 20% of the patients in the facility had no co-occurring psychiatric illness.


5. During an interview with the Chief Executive Officer on 11/19/14, at 10:45 a.m., she acknowledged that the facility was primarily engaged in chemical dependency treatment. She stated the facility was "not focused on primary psychiatric" treatment.



D. Document Review


1. A review of the "Texas Star Recovery Schedule" dated 9/10/14, presented as the schedule for groups and activities at the facility, indicated that all therapeutic groups and activities were directed at chemical dependency treatment and no groups were provided to treat primary psychiatric illness.


2. The facility brochure dated 9/14, presented as a description of the program, described the facility as "adult substance abuse treatment" and stated "treatment focuses on 12-Step fundamentals, relapse prevention and development of support systems." The facility "Policy on the Chemical Dependency Program," revised 7/09, stated "the chemical dependency program is a 7 day a week program and is oriented to both detoxification and to inpatient rehabilitation."


3. The "Procedure Index Summary Report" provided by the facility summarizing the "Principal" International Classification of Diseases (ICD) procedure codes for patients discharged from the facility from 6/17/14 to 11/17/14 stated that all 332 patients discharged during this period received alcohol and/or drug detoxification or alcohol and/or drug rehabilitation as the "Principal" treatment at the facility.



II. Treatment Plans

Patient A1 was a 60 year-old, admitted on 11/10/14. The Psychiatric Evaluation dated 11/10/14 listed Axis I diagnoses of "Alcoholism R/O Bipolar."


Patient A6 was a 35 year-old admitted on 11/12/14. The Psychiatric Evaluation dated 11/14/14 listed Axis I diagnoses of "Alcohol Dependence Benzodiazepine Dep [Dependence] Atypical Dep [Depression]."


Patient B1 was a 31 year-old admitted on 10/31/14. The Psychiatric Evaluation dated 10/31/14 listed Axis I diagnoses of "Opioid dep [dependence], sed-hyp [sedative-hypnotic] dep, PTSD [post-traumatic stress disorder], GAD [generalized anxiety disorder]."


Patient B3 was a 62 year-old admitted 11/04/14. The Psychiatric Evaluation dated 11/5/14 listed Axis I diagnoses of "Mixed substance Dep [dependence]" and "PTSD."


Patient C1 was a 23 year-old admitted 11/10/14. The Psychiatric Evaluation dated 11/10/14 listed Axis I diagnoses of "Opiate Dependence" and "Adjustment disorder [with] depression."


Patient D2 was a 43 year-old admitted on 11/6/14. The Psychiatric Evaluation dated 11/6/14 listed Axis I diagnoses of "Opioid dep, MDD [major depressive disorder, anxiety nos [not otherwise specified]."


Patient D5 was a 38 year-old admitted on 11/2/14. The Psychiatric Evaluation dated 11/2/14 listed Axis I diagnoses of "Stim [stimulant] Depend [dependence] cont [continuous]" and "?Bipolar?"



The Master Treatment Plans (dates in parentheses) for Patient A1 (11/12/14), Patient A6 (11/19/14), Patient B1 (11/13/14), Patient B3 (11/12/14), Patient C1 (11/12/14), Patient D2 (11/13/14), and Patient D5 (11/11/14) were identical as follows:

"Long Term Treatment Goal: Gain insight into recovery that will assist in maintaining long-term sobriety."

"Problem Area: 1" "Short Term Treatment Objective:" "Patient will complete a safe detox with minimal medical complications..."

"Problem Area: 2" "Short Term Treatment Objective: Patient will engage in Rehabilitation therapy by increasing knowledge/understanding of addiction, recovery, and relapse potential. Patient will be able to verbalize improved insight into addiction and will have a plan for recovery..."

"Problem Area: 3" "Short Term Treatment Objective: Patient will work on developing a sober system and realistic discharge plan... "

Problem Area: 4" "Short Term Treatment Objective: Patient will work on reducing the intensity of mental health symptoms via therapy and medication management..."

No specific Problems, Goals, or Interventions were documented in the Master Treatment Plans specifically to provide treatment of psychiatric illnesses.



III. Psychiatric Evaluations

A. Patient A3 was a 54 year-old, admitted on 11/14/14. The Psychiatric Evaluation dated 11/15/14 included an Axis I diagnoses of "bipolar I." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


B. Patient A6 was a 35 year-old, admitted on 11/12/14. The Psychiatric Evaluation dated 11/14/14 included an Axis I diagnosis of "Atypical Dep [Depression]." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


C. Patient B1 was a 31 year-old, admitted on 10/31/14. The Psychiatric Evaluation dated 10/31/14 included an Axis I diagnoses of "PTSD [post-traumatic stress disorder]" and "GAD [generalized anxiety disorder]." The Psychiatric Evaluation did not contain the necessary information to justify these diagnoses and planned treatment.


D. Patient B3 was a 62 year-old, admitted on 11/4/14. The Psychiatric Evaluation dated 11/5/14 included a diagnosis of "PTSD." The following sections were blank: Chief Complaint, History of Present Illness and Precipitating Events, History of Drug/Alcohol use, Past Psychiatric History, Past Medical History, Significant Laboratory Data, Family History, Social History, Allergies, and Medications. The "History of Present Illness and Precipitating Events" stated "see Psych [psychiatric] consult." The psychiatric consultation presented by the facility as the consultation that was referenced in the Psychiatric Evaluation was documented 13 days prior to admission on 10/22/14 and did not contain the information necessary to justify this diagnosis and planned treatment.


E. Patient C1 was a 23 year-old, admitted 11/10/14. The Psychiatric Evaluation dated 11/10/14 included an Axis I diagnosis of "Adjustment disorder [with] depression." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


F. Patient D2 was a 43 year- old, admitted on 11/6/14. The Psychiatric Evaluation dated 11/6/14 included Axis I diagnoses of "MDD [major depressive disorder], anxiety nos [not otherwise specified]." The Psychiatric Evaluation did not contain the necessary information to justify these diagnoses and planned treatment.



IV. Discharge Summaries


A. The Discharge Summary for Patient E1 dated 10/12/14, stated that Patient E1was discharged 9/22/14 with discharge diagnoses including "Post-traumatic stress disorder (PTSD)." The "Hospital Course" did not identify any assessment or treatment of "post-traumatic stress disorder" or other psychiatric illness.


B. The Discharge Summary for Patient E2 dated 9/23/14, stated that Patient E2 was discharged 9/23/14 with discharge diagnoses including "Depression, not otherwise specified (NOS)" and "Generalized anxiety disorder." The "Hospital Course" did not identify any assessment or treatment of "depression, NOS," "generalized anxiety disorder," or other psychiatric illness.


C. The Discharge Summary for Patient E3 dated 9/23/14, stated that Patient E3 was discharged 9/23/14 14 with discharge diagnoses including "Major depressive disorder" and "Post-traumatic stress disorder (PTSD)." The "Hospital Course" did not identify any assessment or treatment of "major depressive disorder," "post-traumatic stress disorder," or other psychiatric illness.


D. The Discharge Summary for Patient E4 dated 10/1/14, stated that Patient E4 was discharged 9/24/14 with discharge diagnoses including "Bipolar illness, mixed." The "Hospital Course" did not identify any assessment or treatment of "Bipolar illness, mixed" or other psychiatric illness.


E. The Discharge Summary for Patient E5 dated 10/12/14, stated that Patient E5 was discharged 9/26/14 with discharge diagnoses including "Atypical depression" "Post-traumatic stress disorder (PTSD)," "Generalized anxiety disorder (GAD)," and "Bipolar II." The "Hospital Course" did not identify any assessment or treatment of "Atypical depression," "Post-traumatic stress disorder (PTSD)," "Generalized anxiety disorder (GAD)," "Bipolar II," or other psychiatric illness.

Based on observations, records review, interviews and documents review, the facility failed to:


I. Ensure that a psychiatric evaluation documented contained sufficient information to justify psychiatric diagnoses and treatment for five (5) of eight (8) active sample patients (A3, A6, B1, C1, and D2) and that a completed psychiatric evaluation was completed for 1 of eight (8) active sample patients (B3). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses. (Refer to B110)


II. Based on records review and interviews, the facility failed to develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on the individual patient needs. (Refer to B118).


III. Provide active psychiatric treatment for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5). These patients received primarily substance abuse treatment during their hospitalization. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician. No other interventions were specifically designed for the treatment of psychiatric conditions. Master Treatment Plans listed Problems and Goals that focused on substance abuse treatment. All group treatments were focused on chemical dependency treatment. The failure to identify psychiatric issues and provide treatment results in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital. (Refer to B125).


IV. Provide a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the assessments and treatments provided for a psychiatric illness for five (5) out of five (5) discharged patients (E1, E2, E3, E4, and E5). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan for psychiatric illnesses with providers providing follow-up care. (Refer to B133)

Based on observations, records review, interviews and documents review, the facility failed to:


I. Provide physicians with adequate training or supervision to provide psychiatric services including the diagnosis and treatment for four (4) of eight (8) active sample patients (A3, B1, D2, and D5) who had general physicians as attending physicians. (Refer to B142)


II. Provide a Medical Director who met the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry. (Refer to B143)


III. Ensure that the Medical Director monitored and took the needed corrective actions to:


A. Ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for five (5) of eight (8) active sample patients (A3, A6, B1, C1, and D2) and that a completed psychiatric evaluation was completed for 1 of eight (8) active sample patients (B3). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses. (Refer to B144)


B. Ensure that staff developed and documented Master Treatment Plans based on the individual patient needs for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B118)


C. Ensure that staff developed Master Treatment Plans that include short term and long term goals stated in observable, measurable, behavioral terms for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B121)


D. Ensure that staff developed Master Treatment Plans that included active treatment measures that addressed the individual patients' specific problems and treatment for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B123)


E. Ensure that staff developed Master Treatment Plans that include the assigned treatment team members responsible for treatment interventions for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B123)


F. Ensure that staff provided active psychiatric treatment for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5). These patients received primarily substance abuse treatment during their hospitalization. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician. No other interventions were specifically designed for the treatment of psychiatric conditions. Master Treatment Plans listed Problems and Goals that focused on substance abuse treatment. All group treatments were focused on chemical dependency treatment. The failure to identify psychiatric issues and provide treatment results in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital. (Refer to B144)


G. Ensure that medical staff provided a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the assessments and treatments provided for a psychiatric illness for five (5) out of five (5) discharged patients (E1, E2, E3, E4, and E5). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan for psychiatric illnesses with providers providing follow-up care. (Refer to B144)

Based on a tour, review of records and interview, it was determined that the psychiatric facility failed to provide an environment that was safe for patients who were at risk for committing suicide.


Findings were:


A tour of the facility on 11/17/14, revealed that the restrooms located in patient rooms throughout the psychiatric facility (referred to as the Pecos building), had open plumbing around the sink and toilets that a ligature could be hung from and potentially used by patients at risk for suicide.


Additionally, in the patient common area there was a phone and a respiratory medical device with cords long enough to be used as ligatures. At the time of the tour, two patients on the unit were on suicide precautions. These patient's medical records were reviewed on 11/18/14.


Patient #1:

Physician Admission Orders dated 11/14/14 at 1345 (1:45 PM) had "Suicide" circled under the "Precaution Status". As of the date of the record review (11/18/14), there had not been an order to discontinue this Precaution Status. The Nursing Assessments for Patient #1 from 11/14/14 through 11/17/14 had a box checked for "Suicide" under the "Precaution" area of the form.


Patient # 2:

Physician Admission Orders dated 11/14/14 at 1600 (4:00 PM) had "Suicide" circled under the "Precaution Status". As of the date of the record review (11/18/14), there had not been an order to discontinue this Precaution Status. The Nursing Assessments for Patient #2 from 11/14/14 through 11/17/14 had a box checked for "Suicide" under the "Precaution" area of the form.


During the tour on 11/17/14, Staff # 2 confirmed the above findings present in the patient restrooms.

Based on a review of documentation and interviews, it was determined that the facility medical staff failed to examine the credentials of all eligible candidates for medical staff membership and failed to make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, as evidence by physicians caring for pateint with psychiatric diagnoses, while not having privileges to provide those services.


Findings included:


Facility based "Medical Staff Bylaws/Rules and Regulations" stated in part,
"2.1 Purposes

The purposes of the Medical Staff are ...

2.1.5 to assure that each Medical Staff Member and Allied Professional provides services within the scope of individual Clinical Privileges granted, and ...

7.1 Exercise of Privileges

Every Member, And Allied Health Professional providing direct services by virtue of his Staff status shall, except as provided in Sections 7.4 be entitled to exercise only those Clinical Privileges specifically granted to him by the Board ...

7.2 Delineation of Privileges in General ...

7.2.2 Basis for Privileges Determinations. Requests for Clinical Privileges shall be evaluated on the basis of the Member of Allied Health Professional's education; course work; training; treatment results; experience; character; peer recommendations; and demonstrated judgment and ability to provide, with reasonable accommodation, safe and competent care; and physical, mental, and emotional capability, as related to the performance of the Privileges requested ..."


Review of the credentialing files of physicians providing care at the facility revealed that 2 physicians did not have privileges granted related to providing psychiatric care.


· Staff member # 6 had a privilege form for "General/Family Practice" that did not indicate any privileges for psychiatric services. The one item on the form that referred to mental health was "Prescribing medications for emotional and medical illness".


· Staff member # 7 had a privilege form entitled "Addiction Medicine" that did not indicate any privileges for psychiatric services. The privilege form addressed treatment of addictive disease and substance abuse.



The privileging forms were different for these two physicians. Both of the above medical staff members were providing direct patient care to clients with substance abuse issues and psychiatric diagnoses at the facility.


In an interview on 11/18/14, Staff member # 4 was asked about the lack of privileging in psychiatry for the two physicians. Staff member # 4 confirmed that the two physicians provided psychiatric care to patients at the facility: performing assessments, treatment plans, and prescribing medications. Staff member # 4 was asked why the privileging forms differed for the above staff members. Staff member # 4 replied, "When they re-privileged you mean? I can't tell you why, maybe the form changed. He's a General Practitioner and he's a podiatrist that concentrated in pain management."


Staff member #4 was asked if the facility treats chemical/substance dependency exclusively. Staff member #4 replied, "I believe there are patients that come in with alcohol and drug addiction that are also depressed ...Yes, they do manage these patients. When they (staff members # 6 and 7) feel they can't manage, they will suggest at times the benefit of [the Medical Director] looking at the patient ...I believe there are patients that their psychiatric issues are a major part of their chemical dependency."


Staff member # 4 was asked if Staff member # 6 and 7 are competent to provide psychiatric care to patients. Staff member # 4 replied, "I think they're competent to do, how should I put this? I think they're competent to do psychiatry at the level they're doing it with consultative help."


In an interview on 11/18/14, Staff member #4 confirmed that the privileges granted to physicians should reflect the full scope of services that are provided at the facility, which includes psychiatric services, not just substance/chemical dependency.

Based on records review and interviews, the facility failed to ensure that a psychiatric evaluation documented contained sufficient information to justify psychiatric diagnoses and treatment for five (5) of eight (8) active sample patients (A3, A6, B1, C1, and D2) and that a completed psychiatric evaluation was completed for 1 of eight (8) active sample patients (B3). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses.


Findings include:


A. Record review


1. Patient A3 was a 54 year-old, admitted on 11/14/14. The Psychiatric Evaluation dated 11/15/14, included an Axis I diagnoses of "bipolar I." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


2. Patient A6 was a 35 year-old, admitted on 11/12/14. The Psychiatric Evaluation dated 11/14/14, included an Axis I diagnosis of "Atypical Dep [Depression]." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


3. Patient B1 was a 31 year-old, admitted on 10/31/14. The Psychiatric Evaluation dated 10/31/14 included an Axis I diagnoses of "PTSD [post-traumatic stress disorder]" and "GAD [generalized anxiety disorder]." The Psychiatric Evaluation did not contain the necessary information to justify these diagnoses and planned treatment.


4. Patient B3 was a 62 year-old, admitted on 11/4/14. The Psychiatric Evaluation dated 11/5/14, included a diagnosis of "PTSD." The following sections were blank: Chief Complaint, History of Present Illness and Precipitating Events, History of Drug/Alcohol use, Past Psychiatric History, Past Medical History, Significant Laboratory Data, Family History, Social History, Allergies, and Medications. The "History of Present Illness and Precipitating Events" stated "see Psych [psychiatric] consult." The psychiatric consultation presented by the facility as the consultation that was referenced in the Psychiatric Evaluation was documented 13 days prior to admission on 10/22/14, and did not contain the information necessary to justify this diagnosis and planned treatment.


5. Patient C1 was a 23 year-old admitted 11/10/14. The Psychiatric Evaluation dated 11/10/14 included an Axis I diagnosis of "Adjustment disorder [with] depression." The Psychiatric Evaluation did not contain the necessary information to justify this diagnosis and planned treatment.


6. Patient D2 was a 43 year- old, admitted on 11/6/14. The Psychiatric Evaluation dated 11/6/14 included Axis I diagnoses of "MDD [major depressive disorder], anxiety nos [not otherwise specified]." The Psychiatric Evaluation did not contain the necessary information to justify these diagnoses and planned treatment.



B. Staff Interviews


1. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he acknowledged that the Psychiatric Evaluations for Patients A3, A6, B1, C1, and D2 did not include documentation of the assessment and treatment of identified psychiatric diagnoses. He acknowledged that no Psychiatric Evaluation was documented for Patient B3 within 60 hours of admission. He stated "I think all patients [admitted to the facility] need a psychiatric assessment by a psychiatrist." He stated that not all patients were evaluated by a psychiatrist. He stated that he was available for consultation but that "sometimes I don't hear about patients I should see [assess]."


2. During an interview with the Medical Director on 11/18/14, at 2:40 p.m., he acknowledged that the Psychiatric Evaluations for Patients A3, A6, B1, C1, and D2 did not include documentation of the assessment and treatment of identified psychiatric diagnoses. He acknowledged that no Psychiatric Evaluation was documented for Patient B3 within 60 hours of admission.

Based on records review and interviews, the facility failed to develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on the individual patient needs. Specifically, the facility fai1ed to develop and document treatment plans that:


I. Included patient goals/short term objectives based on the individual needs of seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). This resulted in a document that failed to identify expected treatment outcomes in a manner that could be understood by treatment staff and patients. (Refer to B121)


II. Included individualized treatment interventions based on the needs of seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). The interventions were generic and described routine discipline functions and interventions that failed to include frequency and/or delivery method. This resulted in staff being unable to provide consistent and focused treatment. (Refer to B122)


III. Identified the assigned treatment team members responsible for treatment interventions for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). Identification of those staff members responsible for ensuring compliance with particular aspects of the patient's MTP essential to the provision of care. Uncoordinated care in which clinical team members do not understand their assigned duties or the assigned duties of their colleagues can result in delay of the patient's discharge and recovery. (Refer to B123)

Based on records review, policies review and interviews, the facility failed to develop Master Treatment Plans (MTP) that included appropriate short-term and long-term goals for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). The focus was chemical dependency treatment. The MTP long term goal and short term goal were consistent for all of these patients. They were non-measurable and lacked dates for goal achievement. Failure to specify patient goals on MTPs hampers staffs' ability to provide goal-directed care and measure patients' responses to treatment potentially resulting in prolonged hospitalizations.


Findings include:


A. Record Review (dates of MTPs in parentheses)


1. For Patients A1 (11/12/14), A6 (11/19/14), B1 (11/13/14), B3 (11/5/14), C1 (11/12/14), D2 (11/13/14) and D5 (11/4/14), the long term treatment goal was; "Gain insight into recovery that will assist in maintaining long-term sobriety." The short term treatment objective was; "Patient will complete a safe detox with minimal medical complications. Expected completion of objective between 1 day and 10 days of admission." The goal/objectives were not measurable in behavioral terms.


B. Policy Review


Review of Policy #3.4, titled "The Administrative Policy on Treatment Planning" page 6 of 10 states in Treatment Plan Goals section #28: "Goals should be functional, observably measurable, documentable, and time limited. Goals will build on or develop the patient's functional strengths. Goals should specify:

a. Who
b. Will do what
c. To what extent
d. Under what conditions"


C. Interview


1. During a review of treatment plan goals/objectives on 11/17/14, at 11:00 a.m., on the unit, RN3 stated the she had never noticed the redundancy of the goals/objectives and proceeded to say; "we (nurses) don't write in the master treatment plan."


2. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he acknowledged that the treatment plans for the sample patients were identical and documented generic goals.

Based on records review and interviews, the facility failed to ensure that the treatment plans for seven (7) or eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5) identified active treatment measures that addressed the individual patients' specific problems and treatment. Instead, the either listed routine and generic discipline functions inappropriately written as treatment interventions or listed general groups/activities to be provided for all the patients as the intervention. The listed groups/activities, by title only failed to include the specific focus or duration of treatment. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. The failure potentially results in inconsistent and/or ineffective treatment.


Findings include:


A. Record Review


1. Patient A1 (11/12/14) Problem #1 was "Detoxification Withdrawal;" Problem #2 was "Addiction;" Problem #3 was "Potential for Relapse;" Problem #4 was "Bipolar Disorder."

The interventions for the 4 problems were listed as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"
These are not treatment modalities with a declared duration and frequency. In addition, no specific psychiatric interventions are listed for the treatment of Bipolar Disorder.


2. Patient A6 (11/19/14) Problem #1 was "Detoxification Withdrawal"

The interventions for problem #1 was listed as follows:

Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week


2. Patient A6 (11/19/14) Problem #2 was "Addiction": Problem #3 was "Potential for Relapse" and Problem #4 was "Anxiety."

The interventions for problem #2, 3 and 4 was identical:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week"
These are not treatment modalities with a declared duration and frequency. In addition, it is reported in the "Review of Progress" section on the patient's MTP that the patient is medication compliant and the MTP.


3. Patient C1 (11/12/14) Problem # 1 was "Detoxification", Problem #2, was "Addiction". Problem #3 was "Potential for Relapse"; and Problem #4 was "Depression".

The intervention for all of the 4 problems was as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"


These intervention listed generic functions and groups without a specific focus, frequency or duration to help meet the patient's needs. The short-term objective for problem #4 Depression states that the "Patient will work on reducing the intensity of mental health symptoms via therapy and medication management" Specifics are not listed in the interventions.


4. Patient D5 (11/4/14) Problem #1 was "Detoxification Withdrawal".

The interventions for problem #1 was as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"


4. Patient D5, Problem #2 was "Addiction"; problem #3 was "Potential for Relapse" and problem #4 was "Anxiety."

The interventions for these problems were as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned problem
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week "
These are not treatment modalities with a declared duration and frequency. In addition, it is reported in the "Review of Progress" section on the patient's MTP that the patient is medication compliant and med are being adjusted to meet s/his mental health needs (Anxiety). However this medication or frequency is not listed on the MTP.



5. Patient B1 (11/13/14) Problem #1 was "Detoxification Withdrawal"

The interventions for problem #1 were listed as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Rehab group, Daily, Person Responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"


5. Patient B1, Problem #2, was "Addiction"; problem #3 was "Potential for Relapse" and problem # 4 was "Anxiety."

The interventions for these problems were as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned problem
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week"
These are not treatment modalities with a declared duration and frequency. In addition, it is reported in the "Review of Progress" section on the patient's MTP that the patient is medication compliant and med are being adjusted to meet s/his mental health needs (Anxiety). However this medication or frequency is not listed on the MTP.


6. Patient B3 (11/5/14), Problem #1 was "Detoxification Withdrawal"; problem #2 was "Addiction"

The interventions for these two problems was as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Rehab group, Daily, Person Responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"


7. Patient B3, Problem #3 was "Potential for Relapse" and problem #4 was "Anxiety."

The interventions for these problems were as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned problem
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week"
These are not treatment modalities with a declared duration and frequency. In addition, it is reported in the "Review of Progress" section on the patient's MTP that the patient is medication compliant and med are being adjusted to meet s/his mental health needs (Anxiety). However this medication or frequency is not listed on the MTP.



8. Patient D2 (11/13/14) Problem #1 was "Detoxification Withdrawal" and Problem #2 was "Addiction".

The interventions for these two problems were as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned
Rehab group, Daily, Pers D2on Responsible: LCSW/LCDC as Assigned
Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week
Stress Management Therapy, 1x Week"


9. Patient D2, Problem #3 was "Potential for Relapse" and problem #4 was "Depression".

The interventions for these two problems were as follows:

"Assessment with Physician, minimum 3x week; Medication adjustment
Medications, Vitals, q15 minute monitoring, Medication Education; Teachings; nursing staff
Individual, 1xWeek, or as needed. Person responsible: LCSW/LCDC as Assigned problem

Group, Daily, Person Responsible: LCSW/LCDC as Assigned
Family Therapy, as deemed necessary: LCSW/LCDC as Assigned
Family Education Group, 1x Week: LCSW/LCDC as Assigned
Recreation Therapy, 2x Week"


These intervention listed generic functions and groups without a specific focus, frequency or duration to help meet the patient's needs. The short-term objective for problem #4 Depression states that the "Patient will work on reducing the intensity of mental health symptoms via therapy and medication management" Specifics are not listed in the interventions.


B. Interview


1. Review of the MTP's with RN4 on the unit at 11:00 am, the question was posed; "why do some interventions make reference to a "Rehab" group and others don't?" The response was; "I have no idea. All patients get the same treatment, and attend the same substance abuse groups."


2. Review of the MTP with RN3 on the unit at 2:00 pm, the generic MTP of active sample patient D5 was discussed. RN3 did not dispute the findings and offered her thoughts that the interventions are a "template that someone on the team clicks on."


3. During an interview with MD 1 on 11/19/14 at 10:00 a.m., he acknowledged that the treatment plans contained only generic interventions for Patients A1, A3, A6, B1, B3, C1, D2, and D5.


4. During an interview with the Medical Director on 11/18/14 at 2:40 p.m., he acknowledged that the treatment plans contained only generic interventions for Patients A1, A3, A6, B1, B3, C1, D2, and D5.

Based on records review and interviews, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the MTP of seven (7) of eight (8) treatment plans for active sample patients (A1, A6, B1, B3, C1, D2, and D5). This practice resulted in the facility's inability to monitor staff accountability for specific treatment modalities.


Findings include:


A. Record Review


Review of the following MTP (dates in parentheses) revealed that the facility did not delineate the names and responsibilities, i,e, interventions of treatment team members for the following active sample patients. Patients A1 (11/12/14), A6 (11/19/14), B1 (11/13/14), B3 (11/5/14), C1 (11/12/14), D2 (11/13/14) and D5 (11/4/14).


B. Interview


In an interview with RN3 on 1/18/14 at approximately 11:45a.m.on the unit, she stated; "we do have this front page that lists all of the team members but we don't designate who is assigned an intervention. I don't know who is specifically responsible. It's just the treatment team members but usually three staff attend the treatment team reviews."

Based on observations, interviews, and documenst review, the facility failed to provide active psychiatric treatment for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5). These patients received primarily substance abuse treatment during their hospitalization. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician. No other interventions were specifically designed for the treatment of psychiatric conditions. Master Treatment Plans listed Problems and Goals that focused on substance abuse treatment. All group treatments were focused on chemical dependency treatment. The failure to identify psychiatric issues and provide treatment results in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital.


Findings include:


A. Observations and Interviews


1. During an observation of the "Rehab Group" conducted by SW 1 on 11/1714, at 11:00 a.m., SW 1 involved the patients in a discussion of an aspect of the "12-Step" program. No issues specifically regarding psychiatric illness were addressed during this group. During an interview with SW 2 on 11/17/14, at 11:40 a.m., he stated that the groups he conducted in the facility were focused on chemical dependency treatment.


2. During an observation of the "REC Therapy" group conducted by RT 1 on 11/17/14, at 2:00 p.m., the patients completed a worksheet identifying leisure activities and other "habits" they could develop during periods of sobriety. No issues specifically regarding psychiatric illness were addressed during this group. During an interview with RT 1 on 11/17/14, at 2:25 p.m., she reported that she conducted two groups per week. She stated that both groups were related to chemical dependency. She stated that one group was provided to assist patients to "learn outlets they can do when sober" and the other to improve their relationship with their "sponsor" after discharge.


3. During an observation of the "Dual Diagnosis" group conducted by Chemical Dependency Counselor 1 on 11/18/14, at 12:30 p.m., the group focused on recovery from chemical dependency. No issues specifically regarding psychiatric illness were addressed during this group.


B. Patient Interview


During an interview with Patient A1 on 11/17/14, at 1:30 p.m., S/he stated that s/he was admitted to the facility for "drinking too much...just the drinking. I don't have problems with my nerves."


C. Staff Interviews

1. During an interview with the Clinical Admissions Specialist on 11/18/14, at 12:05 p.m., she stated that facility accepted patients for admission using specific criteria documented on the "Admission Criteria - Adult Chemical Dependency" form including the following: "All of the following criteria must be met:" "the primary need for treatment is drug and/or alcohol dependency; a co-existing psychiatric condition may be present, but must not be the primary reason for admission."


2. During an interview with the Director of Nursing 11/18/14, at 1:15 p.m., he was unable to identify any psychiatric treatment being conducted by nursing staff other than medication administration. He stated that the psychiatric treatment was "not what it should be." He stated that the facility was "lacking in psychiatric treatment" by nursing staff and the facility "could do a better job."


3. During an interview with the Clinical Director on 11/17/14, at 2:40 p.m., she stated that the facility screened potential patients to ensure that they required primarily chemical dependency treatment. She stated "although we take some dual diagnosis [patients], if they are primarily psychiatric, we refer them to another psych [psychiatric] facility." She stated that the programming for the unit was designed for "the population [inpatient chemical dependency] we are working with." She estimated "85% [of the patients] require detox, then step down to rehab." She stated that social work staff met with the patients but did not provide individual therapy. She stated "most of it [treatment] is group-based." During an interview with the Clinical Director on 11/18/14 at 3:50 p.m., she acknowledged that the facility was primarily engaged in chemical dependency treatment. She stated the facility was "not focused on primary psychiatric" treatment.


4. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he stated that the "whole thrust of all the groups" provided at the facility was "geared toward" chemical dependency treatment. He acknowledged that all groups were based in the 12 Step-Program. He estimated that 20% of the patients in the facility had no co-occurring psychiatric illness.


5. During an interview with the Chief Executive Officer on 11/19/14, at 10:45 a.m., she acknowledged that the facility was primarily engaged in chemical dependency treatment. She stated the facility was "not focused on primary psychiatric" treatment.


D. Document Review


1. A review of the "Texas Star Recovery Schedule" dated 9/10/14, presented as the schedule for groups and activities at the facility, indicated that all therapeutic groups and activities were directed at chemical dependency treatment and no groups were provided to treat primary psychiatric illness.


2. The facility brochure dated 9/14, presented as a description of the program, described the facility as "adult substance abuse treatment" and stated "treatment focuses on 12-Step fundamentals, relapse prevention and development of support systems." The facility "Policy on the Chemical Dependency Program," revised 7/09, stated "the chemical dependency program is a 7 day a week program and is oriented to both detoxification and to inpatient rehabilitation."


3. The "Procedure Index Summary Report" provided by the facility summarizing the "Principal" International Classification of Diseases (ICD) procedure codes for patients discharged from the facility from 6/17/14 to 11/17/14 stated that all 332 patients discharged during this period received alcohol and/or drug detoxification or alcohol and/or drug rehabilitation as the "Principal" treatment at the facility.

Based on records review and interviews, the facility failed to complete a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the assessments and treatments provided for a psychiatric illness for five (5) out of five (5) discharged patients (E1, E2, E3, E4, and E5). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan for psychiatric illnesses with providers providing follow-up care.


Findings include:


A. Record Review


A. The Discharge Summary for Patient E1 dated 10/12/14, stated that Patient E1was discharged 9/22/14, with discharge diagnoses including "Post-traumatic stress disorder (PTSD)." The "Hospital Course" did not identify any assessment or treatment of "post-traumatic stress disorder" or other psychiatric illness.


B. The Discharge Summary for Patient E2 dated 9/23/14, stated that Patient E2 was discharged 9/23/14, with discharge diagnoses including "Depression, not otherwise specified (NOS)" and "Generalized anxiety disorder." The "Hospital Course" did not identify any assessment or treatment of "depression, NOS," "generalized anxiety disorder," or other psychiatric illness.


C. The Discharge Summary for Patient E3 dated 9/23/14, stated that Patient E3 was discharged 9/23/14 14, with discharge diagnoses including "Major depressive disorder" and "Post-traumatic stress disorder (PTSD)." The "Hospital Course" did not identify any assessment or treatment of "major depressive disorder," "post-traumatic stress disorder," or other psychiatric illness.


D. The Discharge Summary for Patient E4 dated 10/1/14, stated that Patient E4 was discharged 9/24/14, with discharge diagnoses including "Bipolar illness, mixed." The "Hospital Course" did not identify any assessment or treatment of "Bipolar illness, mixed" or other psychiatric illness.


E. The Discharge Summary for Patient E5 dated 10/12/14, stated that Patient E5 was discharged 9/26/14 with discharge diagnoses including "Atypical depression" "Post-traumatic stress disorder (PTSD)," "Generalized anxiety disorder (GAD)," and "Bipolar II." The "Hospital Course" did not identify any assessment or treatment of "Atypical depression," "Post-traumatic stress disorder (PTSD)," "Generalized anxiety disorder (GAD)," "Bipolar II," or other psychiatric illness.


B. Interviews


During an interview with MD 1 on 11/19/14, at 10:00 a.m., he acknowledged that the discharge summaries for Patients E1, E2, E3, E4, and E5 did not include documentation of the assessment and treatment of identified psychiatric diagnoses. He stated that the information should have been included because the aftercare providers "need to know" this information.

Based on records review, documents review and interviews, the facility failed to provide physicians with adequate training or supervision to provide psychiatric services including the diagnosis and treatment for four (4) of eight (8) active sample patients (A3, B1, D2, and D5) who had general physicians as attending physicians.


Findings include:


A. Record Review


A review of the medical records for Patients A3, B1, D2, and D5 revealed no documentation of the involvement of a psychiatrist in the psychiatric evaluation or treatment planning for these patients or of the supervision of the diagnosis and treatment provided by a qualified psychiatrist.


B. MD 2

1. A review of the Curriculum Vitae for MD 2 indicated that MD 2 completed a residency in Family Medicine but did not complete psychiatry residency training.


2. A review of the "General/Family Practice" privileges dated 7/28/14, granted to MD 2 by the facility stated his "Scope of Practice May Include: Admission and medical treatment of child, adolescent or adult non-surgical patients without life-threatening complications." Privileges requested were: "Hospital admission," "Admission history and physical on patients," "Prescribing medications for emotional and medical illness," "Referral of patients for consultations and treatment on and off campus," "Transfer of patients to other hospitals for evaluation of and treatment procedures for medical illnesses (general surgery)," "Prescribing ancillary therapy services: speech therapy, physical therapy, occupational therapy, cognitive rehabilitation," and "EKG Interpretation." The privilege form did not indicate that MD 2 was granted privileges for the assessment and treatment of psychiatric illnesses.


3. During an interview with MD 2 on 11/18/14, at 9:15 a.m., he stated that he was the attending physician for Patients A3, B1, and D2. He stated that his training was in Family Medicine and that acknowledged that he was not eligible for board certification in psychiatry or trained in psychiatry.


C. MD 3


1. A review of the Curriculum Vitae for MD 3 indicated that MD 3 completed a residency in Physical Medicine and Rehabilitation and a fellowship in Pain Management but did not complete psychiatry residency training.


2. A review of the "Addictive Medicine General Privileges" dated 2/6/13, granted to MD 3 by the facility stated his "Scope of Practice May Include: Admission work up, evaluation, diagnosis, and provision of non-surgical treatment including consultation for patients admitted or in need of care to treat general medical problems." "Privileges" requested were: "Hospital admission," "Admission medical history and physical," "Consultation, diagnosis and treatment of addictive diseases and substance abuse," "Pharmacologic therapy of addictive disease," "General medical management," "Detoxification management," "Substance abuse therapy, for family individual, group, and marital," "Referral of patients for partial hospitalization programs, intensive outpatient programs, residential treatment centers and outpatient treatment." The privilege form did not indicate that MD 2 was granted privileges for the assessment and treatment of psychiatric illnesses.


3. During an interview with MD 3 on 11/18/14, at 12:15 p.m., he stated that he was the attending physician for Patient D5. He stated that his training was in Physical Medicine and Pain Management and acknowledged that that he was not eligible for board certification in psychiatry or trained in psychiatry.


D. Interviews


1. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he stated that he was the only trained psychiatrist in the facility. He stated that he did not directly supervise or review the psychiatric treatment provided by MD 2 or MD 3. He stated "I think all patients [admitted to the facility] need a psychiatric assessment by a psychiatrist." He stated that not all patients were evaluated by a psychiatrist. He stated that he was available for consultation but that "sometimes I don't hear about patients I should see [assess]."


2. During an interview with the Medical Director on 11/18/14, at 2:40 p.m., he acknowledged that the psychiatric care provided by MD 2 and MD 3 was not directly supervised or reviewed by a psychiatrist.

Based on interviews and documents review, the Medical Director failed to meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry.


Findings include:


A. Document Review


The Curriculum Vitae for the Medical Director did not indicate the training or experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry. The Curriculum Vitae indicated training and board certification in internal medicine.


B. Staff Interview


During an interview with the Medical Director on 11/18/14, at 2:40 p.m., he stated that he did not complete training in psychiatry and was only board-certified in internal medicine.

Based on records review and interviews, the Medical Director failed to:


I. Ensure that a psychiatric evaluation documented contained sufficient information to justify psychiatric diagnoses and treatment for five (5) of eight (8) active sample patients (A3, A6, B1, C1, and D2) and that a completed psychiatric evaluation was completed for 1 of eight (8) active sample patients (B3). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses. (Refer to B110)


II. Ensure that staff developed and documented Master Treatment Plans based on the individual patient needs for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B118)


III. Ensure that staff developed Master Treatment Plans that include short term and long term goals stated in observable, measurable, behavioral terms for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B121)


IV. Ensure that staff developed the Master Treatment Plans that included physician treatment interventions for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). This results in the facility not delineating the role of the physician in the treatment of patients.


Findings include:


A. Record Review


The Master Treatment Plans (dates in parentheses) for the following patients documented " Assessment with Physician, minimum 3x week; Medication adjustment " as the only intervention to be performed by the psychiatrist: Patient A1 (11/12/14), Patient A6 (11/19/14), Patient B1 (11/13/14), Patient B3 (11/12/14), Patient C1 (11/12/14), Patient D2 (11/13/14), and Patient D5 (11/11/14).


B. Staff Interview


1. During an interview with MD 1 on 11/19/14, at 10:00 a.m., he acknowledged that the treatment plans contained only generic interventions for Patients A1, A3, A6, B1, B3, C1, D2, and D5.


2. During an interview with the Medical Director on 11/18/14, at 2:40 p.m., he acknowledged that the treatment plans contained only generic interventions for Patients A1, A3, A6, B1, B3, C1, D2, and D5.


V. Ensure that staff developed Master Treatment Plans that include the assigned treatment team members responsible for treatment interventions for seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5). (Refer to B123)


VI. Ensure that staff provided active psychiatric treatment for eight (8) of eight (8) active sample patients (A1, A3, A6, B1, B3, C1, D2, and D5). These patients received primarily substance abuse treatment during their hospitalization. The psychiatric interventions that were offered to patients were routine in nature and involved prescription functions by the physician. No other interventions were specifically designed for the treatment of psychiatric conditions. Master Treatment Plans listed Problems and Goals that focused on substance abuse treatment. All group treatments were focused on chemical dependency treatment. The failure to identify psychiatric issues and provide treatment results in the lack of clear provision of psychiatric care being delivered to patients in a psychiatric hospital. (Refer to B125)


VII. Ensure that medical staff provided a discharge summary for each patient who had been discharged that included a recapitulation of the patient's hospitalization including the assessments and treatments provided for a psychiatric illness for five (5) out of five (5) discharged patients (E1, E2, E3, E4, and E5). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plan for psychiatric illnesses with providers providing follow-up care. (Refer to B133)

Based on records review and interviews, the Director of Nursing (DON) failed to develop and document comprehensive treatment plans that included appropriate nursing interventions to guide nursing staff in the provision of nursing care for patient based on identified problems and behaviors for of seven (7) of eight (8) active sample patients (A1, A6, B1, B3, C1, D2, and D5).


Findings include:


A. Record Review


1. All of the MTP nursing treatment interventions listed "Medications, Vitals, q15 minute monitoring, Medication Education; Teachings: nursing staff." These nursing interventions were listed with non-specific or inappropriate parameters for patient monitoring and interventions based on identified patient needs.


2. The Texas Department of State Health Services: Regulation Y 4.02 State: Private Psychiatric Hospital & CSU (crisis stabilization unit) states; (a) Nursing service in treatment plan. "A hospital shall provide nursing services to a patient in accordance with a treatment plan developed in accordance with #411.471 of this title (relating to Inpatient Mental Treatment and Treating Planning)" (c) A Director of psychiatric nursing (DPN). A hospital shall have a DPN who: (2) directs, monitors, and evaluates the nursing services provided.


B. Interview


Interview with DON of the Texas NeuroRehab Center 11/18/14, at approximately 1 p.m. The surveyor questioned the development of the MTP's. The DON response was; "I've been trying to figure it out, why I'm not involved with Texas Star unit. "