HospitalInspections.org

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

l. Provide treatment plans that identified patient-related, short-term and long-term goals in observable, measurable, behavioral terms for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the goals were often unrelated to the problems identified and were not measurable. This failure results in a document that does not identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

ll. Develop treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the interventions were either absent, generic discipline practice or unrelated to the identified problems and short-term goals. This failure results in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

lll. Ensure that the staff member responsible for each intervention was identified by discipline on the Master Treatment Plan (MTP) in eight of (8) of (8) treatment plans (A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in the patient and other staff being unaware of which staff person, by discipline, is responsible for the intervention being implemented and documented. (Refer to B123)

lV. Ensure that active treatment measures, such as group and/or individual treatment were provided for six (6) of eight (8) active sample patients (A1, A2, A5, A6, A7, and A8) who were unwilling, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patients' lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on records reviewed and interviews, the Hospital failed for one of four contract services reviewed to ensure an accurate contract for Laboratory Services provided at the Hospital.

Findings included:

The Contract titled "Agreement for Laboratory Services between High Point Treatment Center & East Side Clinical Laboratory," dated 8/10/10, indicated a service for phlebotomy (a procedure to withdraw blood for laboratory testing) at the Plymouth Campus. The Contract indicated no documentation for laboratory services at the Hospital Middleboro Campus.

The Surveyor interviewed the Director of Quality & Risk at 9:30 A.M. & 2:15 P.M. on 11/26/18. The Director of Quality & Risk said the Hospital contracted with East Side Clinical Laboratories for laboratory services provided at the Hospital. The Director of Quality & Risk said the Contract was unclear regarding the Hospital location. The Director of Quality & Risk said that the Hospital was previously located in the town of Plymouth and the Contract was not updated after the Hospital relocated to the town of Middleboro in 2015.

Based on observations, records reviewed and interviews, the Hospital failed for two of two pregnant patients (Patients #4 & #31) in a total sample of thirty-four patients, to ensure quality obstetric care and failed for one of four sampled credential files reviewed, that the providerprovided care in the Hospital was in accordance within the scope of Medical Staff privileges granted by the Governing Body. Findings included:

1.) The Surveyor observed, at 10:30 A.M. on 11/26/18, a pregnant woman (Patient #4) standing in the hallway of a Patient Care Unit. The Surveyor observed the pregnant woman to be very pregnant.

The Medical Record document titled "History & Physical (H&P) Examination," dated 11/20/18, indicated Patient #4 was 29 weeks pregnant (third trimester) and admitted to the Hospital for addiction treatment. The H&P indicated an abdominal evaluation that indicated no documentation of a pregnancy. The H&P indicated no documentation of a fetal assessment for a fetal heartbeat (generally a fetal heartbeat can be heard with a Doppler, medical device, at approximately 12 weeks of pregnancy). The H&P indicated no documentation of a plan of care regarding the pregnancy, including vital signs monitoring, weight monitoring, evaluation of patient readiness for obstetric evaluation or patient readiness for childbirth education (generally, begin at 28-32 weeks of pregnancy).

Review of the Provider Notes in the patient medical record, dated 11/19/18 through 11/27/18, indicated only psychiatric provider notes. The psychiatric provider notes indicated no documentation of a plan regarding Patient #4's pregnancy.

The Hospital policy titled: "Admission and Treatment of Pregnant Patients," dated 2/1018, indicated the Medical Director or Designee as responsible for scheduling regular medical appointments with a Medical Doctor or Nurse Practitioner for prenatal care. The Admission and Treatment of Pregnant Patients policy indicated no clear requirements of a pregnancy plan of care for a pregnant woman requiring inpatient psychiatric care. The Admission and Treatment of Pregnant Patients policy indicated no clear requirements for vital sign monitoring including blood pressure, weight checks, and evaluation of preeclampsia (toxemia of pregnancy). The Admission and Treatment of Pregnant Patients policy indicated no clear monitoring of fetal well being. The Admission and Treatment of Pregnant Patients policy indicated no clear guidance for an unexpected delivery.

The Surveyor interviewed Registered Nurse #8 at 10:45 A.M. on 11/26/18. Registered Nurse #8 said that she would assess the patient, review the policy and call 911 (Emergency Medical Services) if a pregnant patient was in imminent delivery.

The Surveyor interviewed the Hospital Administrator at 7:30 A.M. on 11/27/18. The Hospital Administrator said the Medical Director was involved with all pregnant patients at the Hospital.

The Surveyor interviewed the Medical Director at 1:00 P.M. on 11/28/18. The Medical Director said that either he or a Nurse Practitioner provided on-going evaluation of pregnant patients. The Medical Director said the pregnant patients received the same standard for vital sign monitoring as other Hospital patients, and that the Hospital had no specific Obstetric/ gynecolgical (OBGYN) specific care for vital signs or weight monitoring. The Medical Director said that the Hospital did not provide fetal evaluation. The Medical Director said that the Hospital referred pregnant patients for specialty care.

There was no evidence of OBGYN care or referral for care in the medical record for Patient #4.

2. For Patient #31, the Medical Record document titled "H&P", dated 7/8/18, indicated Patient #31 was pregnant.

Review of the nursing note, dated 7/23/18 at 8:17 A.M., indicated Patient #31 went to hospital B for an OBGYN evaluation.

The Ultrasound Report, dated 7/23/18 from hospital B, indicated Patient #31 was 7 weeks pregnant (first trimester).

Provider Notes, dated 7/23/18 through 7/24/18, indicated no documentation of a plan for OBGYN care or referral for continued care regarding Patient #31's pregnancy.


2.) Review of the credentialing files for Nurse Practitioner #1's delineation of privileges indicated the Governing Body privileged Nurse Practitioner #1 to provide only history and physical (H&P) examinations.

The Medical Record document titled "H&P", dated 11/19/18, indicated Nurse Practitioner #1 provided Patient #21's H&P in accordance with Nurse Practitioner's privileges.

The Provider Note, dated 11/23/18, indicated Nurse Practitioner #1 examined Patient #1 for complaints of a cough and evaluated Patient #1 to have wheezing in the lungs. Nurse Practitioner #1 treated Patient #1 with medication for the wheezing with a plan to monitor and follow-up as needed (the evaluation and treatment was inconsistent with Nurse Practitioner #1's privileges granted by the Governing Body).

The Surveyor interviewed the Hospital Administrator at 9:25 A.M. on 11/27/18. The Hospital Administrator said Nurse Practitioner #1 provided follow-up patient care.

The Surveyor interviewed the Chief of Psychiatry and Nurse Practitioner #1 at 10:00 A.M. on 11/27/18. Chief of Psychiatry and Nurse Practitioner #1 said Nurse Practitioner #1 performed patient histories & physical examinations. Chief of Psychiatry and Nurse Practitioner #1 said Nurse Practitioner #1 monitored patients' acute and chronic medical illnesses through the patient's hospitalization to the patient's Hospital discharge. The Chief of Psychiatry and Nurse Practitioner #1 said the NP monitored patient laboratory and diagnostic test results. Nurse Practitioner #1 said she attended patient care meetings and provided medical consultation for the psychiatry providers.

NP #1 was not providing care within the delineation of privileges as granted to her by the Governing body.





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MOVE TO 467 Medical records cite! See SOD

Based on review of a Hospital document titled By-laws the Medical Professional Staff, the Hospital failed to distinguish between the Medical Staff (doctors of medicine, doctors of osteopathy, non-physician practitioners with an advanced scope of practice) and members of the Medical Professional Staff (MPS) that included other clinicians such as nurses.

Findings include

The Hospital document titled By-laws of the Medical Professional Staff, dated 12/14/15, indicated the Hospital had two categories of MPS and they were Active Staff and On-call Staff. The Active Staff qualifications included physician, counselors and advanced practice registered nurses, nurses and other clinicians who were employees of the Hospital. The staff will vote on all matters presented at regular and special meetings of the Medical Professional Staff.

The Surveyor interviewed the Hospital's Administrator at 8:00 A.M. on 11/28/18. The Hospital Administrator said that she planned to ensure the Hospital's Medical Staff develop, adopt an operate under it's own By-Laws, distinct from the Hospital's Medical Professional Staff, which will be approved by the Governing Body.

As defined by the Centers for Medicare and Medicaid, the Medical Staff are doctors of medicine, doctors of osteopathy and non-physician practitioners with an advanced scope of practice who have been determined to be eligible for appointment by the governing body. Nurses and other clinicians not appointed by the governing body are not members of the Hospital Medical Staff, they do not vote at medical staff meetings.

Based on interview and record review the hospital failed to develop and approve nursing service patient care policies and procedures. Findings include:

After the entrance conference on 11/26/18, at 8:00 A.M. The Surveyors requested all Nursing Policies and Procedures.

On 11/26/18, at 12:00 P.M. the hospital submitted a document titled Medication Dispensing Policy, dated 02/2018.

Surveyors reviewed Patient #4's Medication Administration Record (MAR). Patient #4's medical record indicated that his/her physician prescribed Amoxicillin 500 mg by mouth, four times a day for 10 days. The MAR indicated that from 11/21/18 to 11/26/18, Patient #4's Amoxicillin was placed "on hold" 10 times and later documented as administered by the nurse.

Surveyors interviewed Nurse #4 and Nurse #6 on Unit 4, on 11/27/18, at 9:30 A.M. The Surveyor asked Nurse #6 and Nurse #4 about Patient #4's Amoxicillin medication hold. Nurse #6 said that the medication is really not on hold, that the nurses put medication "on hold" so the patient is not dropped from the medication administration page. Nurse #4 then said that he was doing medication administration and showed the Surveyor how placing a patient's medication "on hold" would allow the patient to remain on the computer screen instead of being removed from the screen and counted as a missed medication. Nurse #4 said that if a patient does not want their medication at the administration time due to being in the shower or wanting to sleep later, the nurse places the medication "on hold" so they won't forget to give the medication later. The Surveyor asked if that was the policy for placing the medication on hold, Nurse #4 said that he wasn't sure but that's what they do. When asked about patients that had a true medication hold and how a nurse was to know what medications were placed "on hold" by the physician versus a nurse wanted to give a medication later on? Nurse #4 and Nurse #6 were unable to answer.

The Vice President (VP) of Nursing was interviewed on 11/27/18 at 1:00 P.M. The VP of Nursing said that "medication hold" is to be entered only when ordered by a physician. Medications are not to be administered if a medication is placed "on hold". The VP of Nursing said that her expectation was that "medication hold" was not to be used to keep a patient on the medication screen or as a delayed administration. .

There was no policy or procedure in the Medication Dispensing Policy provided by the hospital to address medication hold procedures.

Based on interview and record review the hospital failed to ensure that patient needs are met by ongoing assessments for 1 patient (#28) out of 33 sampled patients.

Findings include:

Surveyors reviewed Patient # 28's medical records on 11/27/18. Patient # 28 was admitted on 11/24/18 with a past medical history that included hypertension. Patient # 28' s blood pressure was measure as 180/110 at 9:37 A.M. on 11/25/18, 190/110 at 11:53 P.M. on 11/26/18, and 176/108 on 10:57 A.M. There were no indications of a nurses note regarding hypertension or documentation that the Nurse Practitioner or Physician were made aware of Patient #4's hypertension.

Surveyors asked Nurse #4 about Patient #28's documented hypertension. Nurse #4 said he takes the patient's blood pressure in the morning before medication administration. Nurse #4 said that he wasn't sure what vital sign results he would report to the physician before administering medications.

The VP of Nursing said that her expectation was that nurses should have notified either the Nurse Practioner or Physician when Patient # 28's blood pressure was measured as high. The VP of Nursing said that her expectation is to document the blood pressure in a nurse's note and notify the physician with diasystolic blood pressures of 100 or higher.

Based on record review and interview the hospital failed to administer medications in accordance with orders of the physician.

Findings include:

Surveyors reviewed Patient #12's Medication Administration Record (MAR) on 11/26/18. Patient #12's MAR indicated that on 11/26/18, at 9:01 A.M. Patient #12 received 50 Mg of Thorazine (a medication used to treat mental/mood disorders) by mouth. Patient #12's MAR indicated that on 11/26/18, at 11:55 A.M. Patient #12 received another dose of Thorazine 50 Mg by mouth.

Review of Patient #12's admission orders indicated that on 11/24/18, the admitting physician ordered Thorazine 50 mg by mouth every 4 hours as needed.

The Vice President (VP) of Nursing was interviewed on 11/27/18 at 1:00 P.M. The VP of Nursing said that nursing is expected to follow the physician's medication orders. The Vice President (VP) of Nursing acknowledged that the Thorazine was not administered as ordered by the physician.

On 11/27/18, at 9:00 A.M., Surveyors met with the Hospital Administrator. The Hospital Adminstrator said that the hospital did not have a Medication Administration Policy that addressed the five rights of medication administration that the hospital would add this to the existing policy immediately. The Hospital Administrator acknowledged that nurses did administer medications according to the professional standard of care using the 5 rights of medication administration for the above Pateint.

Based on record review, the hospital electronic medical record (EMR) system that the hospital uses does not allow the ability for the actual dose ( total dose of a medication ) ordered by a physician to be given to a patient to be written in the medication administration record (MAR) so that there is a complete order with the name of medication, the dosage to be given, the strength per dosage unit, quantity prescribed and directions for use consistent with the physician's order. Findings include:


The Hospital document titled By-laws of the Medical Professional Staff, dated 12/14/15, indicates under Section 88E, that a medication order must include "the dosage and strength per dosage unit, quantity prescribed and directions for use including any cautionary statements required."

Record review of sampled patients, Patient #8 and Patient #25, indicated medication orders missing total dosage of the medications on the EMR MAR order screens. Record review of non-sampled patients, Patient #1, Patient #2, and Patient #3 indicated medication orders missing total doses on the order medication screens.

The Surveyor interviewed Nurse #6 in IPU (Inpatient Psych Unit)-2. Nurse #6 indicated that the electronic medical record (EMR) system that the hospital uses does not allow the ability for the actual total dose of a given medication to be written under dose. Nurse #6 said that only a number of pills is placed under the category of dose and the nurse must do the manual calculation together with the drug name and strength to come up with the final total dose.

Based on record review and staff interview, the Hospital failed to ensure that the consultant Dietitian assessed Patients that triggered for a Nutrition Assessment, based on medical criteria determined by Nursing when completing the initial Nursing Medical Assessment, for 4 Sampled Patients (#4, #14, #17, #21), from a total sample of 34 Patients.

Findings include:

1. Review of the Hospital Nutrition Screening Policy, revised on 7/2018, indicated that the Nursing staff would evaluate the need for a full nutrition assessment of patients identified at nutrition risk, based on information gathered during the nursing medical assessment/history and throughout the patient's stay. This included medical conditions which warranted a nutrition consult.

Review of the nursing medical assessment indicated that medical conditions with an asterisk (*), including Pancreatitis, Cirrhosis, Gastro by-pass, Pregnancy, Diabetes, special diets, eating disorders, chewing and swallowing problems and unintended weight loss, would immediately trigger for a nutrition consult and be referred to the Nutritionist/Dietitian.

2. For Patient #4, the Hospital staff failed to identify a Patient, who was at nutrition risk, to the Dietitian for a nutrition consult, as per Hospital policy.

Patient #4 was admitted to the Hospital in 11/2018 with diagnoses that included Bipolar disorder, major depression, PTSD, anxiety, Opioid dependence and was approximately 30 weeks pregnant.

Review of the nursing medical assessment, dated 11/19/18, indicated that the patient was pregnant and the section below that in red capital lettering indicated "MUST REFER TO NUTRITIONIST".

Interview with the Dietitian on 11/27/18 at 1:30 P.M. said that the Hospital had identified that there was a computer glitch and she was not receiving nutrition consults as a result. The Dietitian then demonstrated how the computer referral system should work and said that the nurses were sending the consult request but not indicating who the request should go to, therefore the Dietitian never received the nutrition consult via email. The Dietitian said that she did not receive a nutrition consult request for Patient #4.



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3. Patient #14 was admitted to the Hospital in October 2018 with diagnoses which included diabetes.

Review of the Nursing Assessment, dated 10/04/18, indicated that Patient #14 had diabetes, was on Metformin (a medication used to lower blood sugar levels), and that he/she must be referred to the nutritionist.

Review of the Physician's Order, dated 10/31/18, indicated that Patient #14 was started on sliding scale insulin to manage his/her blood sugars.

The Dietician said she had not received a referral to evaluate Patient #14, and had not completed a Nutritional Assessment prior to 11/27/18.


4. Patient #17 was admitted to the Hospital in September 2018.

Review of the Nursing Assessment, dated 09/21/18, indicated that Patient #17 had non-insulin dependent diabetes, and that he/she must be referred to the nutritionist.

Review of the Physician's Order, dated 10/18/18, indicated that Patient #17 was started on sliding scale insulin to manage his/her blood sugars.

The Dietician said that as of 11/27/18, she had not received a referral to evaluate Patient #17 and had not completed a nutritional assessment.



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5. Patient #21 was admitted to the Hospital in November 2018.

Review of the Nursing Assessment, dated 11/19/18, indicated Patient #21 had unknown weight loss and decrease in appetite, and he/she must be referred to the Nutritionist.

Review of the clinical record indicated Resident #21 was discharged to the community on 11/26/18.

The Dietician was interviewed at 3:15 P.M., on 11/27/18. The Dietician reviewed the Nursing Assessment dated 11/19/18, and said she had not received a referral to evaluate Patient #21, and had not completed a Nutritional Assessment prior to Resident #21's discharge on 11/26/18.

Based on observation, record review and staff interview, the Hospital staff ( Diet aide #1 and #2 and the cook) failed to maintain sanitary conditions and prevent cross contamination in the kitchen during the dish machine procedure and meal service, putting the Patients at risk for foodborne illness.

Findings include:

1. On 11/27/18 at 8:45 A.M., the Surveyor observed Diet Aid #1 working at the dish machine. Diet aid #1 was removing soiled food debris from all plates, dishware, silverware and trays and placed them in racks. Diet aid #1 then opened the door of the dish machine and pushed the rack into the machine for cleaning. Diet Aid #1 was then observed removing her disposable gloves and moving to the other side of the dish machine where the clean rack of dishware would be removed from the machine. Diet aid #1 removed the rack and began to remove clean dishware and trays from the rack without washing her hands, therefore contaminating the clean dishware with her dirty hands. The Surveyor asked Diet aid #1 if this process occurred after each meal and she said yes there is only one dietary staff member that completes this task.

Diet Aide #1 was again observed on 11/27/18 between 1:15-1:25 P.M. completing the dishware cleanup procedure at the dish machine. Diet Aid #1 continues to perform the task and not wash her hands before removing the clean dishware from the dish machine, despite having just worked with soiled dishware.

On 11/28/18 at 8:40 A.M., the Food Manager was interviewed and the Surveyor reviewed all observations in the kitchen, including the concern of cross contamination during the dish machine clean up procedure. The Food Manager and the Surveyor then observed Diet Aid #2 performing the dish machine clean up task. Diet aid #2 also was not washing her soiled hands before removing clean dishware.

The Food Manager provide the Surveyor with a Hospital policy titled Ware washing-Commercial Dish Machine Policy, revised on 2/2016. Review of the policy indicated that appropriate sanitation precautions are taken in handling and preparing food, including dishwashing equipment and techniques that result in sanitized service to prevent re-contamination. The policy further indicated that to avoid cross contamination there would be 2 employees assigned to dishwashing with 1 employee handling soiled dishes, trays, and carts and the other employee handling clean dishes, trays and carts when possible. If only 1 employee is available, the employee would wash hands thoroughly before handling clean dishes trays and carts.

The policy was reviewed with the Food Manager who said that the dietary staff did not follow the policy and contaminated the dishware.

2. On 11/27/18 at 12:00 P.M., the Surveyor observed the meal service in the main kitchen. The cook was observed serving the main entree from the steam table. The cook used a utensil with her right hand to place pasta and chicken on a plate, however used her gloved left hand and cradle the food on the plate, touching the food. The cook was observe to repeat this process for 8 plates, then the Surveyor called the Food Manager over to observe. The Food Manager acknowledged the incorrect process of plating the meal and contaminating the food with a dirty gloved hand.

The cook was then observed reaching for A "walkie talkie", located to the left of the steam table. The cook picked up the walkie talkie with the gloved hand and made an announcement. The cook then returned to the steam table and began serving the meal without washing her hands or changing her gloves.

On 11/28/18 at 8:40 A.M. the Surveyor reviewed the meal service observations with the Food Manager, who acknowledged the cross contamination during the meal service.

Based on records reviewed and interviews the Hospital failed to have a policy for referral to their Organ Procurement Organization that included the criteria for referral of all patients whose death was imminent or who had died in the Hospital.

Findings included:

The Hospital policy titled "Organ Donor," dated 1/2016, indicated deaths that fall under the jurisdiction of the Office of the Medical Examiner do not need to be reported to the Organ Procurement Organization.

The Surveyor interviewed the Hospital Administer at 10:00 A.M. on 11/17/18. The Hospital Administer said the Office of the Medical Examiner told her that the Hospital did not need to report deaths that fall under the jurisdiction of the Office of the Medical Examiner to the Organ Procurement Organization (this was not in accordance with Hospital regulations).

Based on record review, policy review, and interview the facility failed to provide social work assessments that included interventions and recommendations to include social work roles in treatment and discharge planning. This practice has the potential to result in an absence of professional social work treatment services for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7, and A8).

Findings Include:

A. Medical Records

1. Patient A1's Biopsychosocial Assessment, dated 11/08/18, failed to define individualized social work treatment recommendations and listed patient goals as follows:

"To be open with the treatment team as to what occurred at the group home and with the staff"
"To resolve [his/her] mental health needs"
"To engage in after care planning"
"To take medication as prescribed"
"To maintain safety"

2. Patient A2's Biopsychosocial Assessment, dated 11/10/18, described both generic social work treatment recommendations and patient goals:

"While the pt. [patient] is at High Point Hospital the patient will be encouraged to partake in group, engage with [his/her] tx [treatment] team on a daily basis, verbalize an understanding of the risk factors that prompted placement at High Point Hospital, work with the aftercare team on a discharge plan, verbalize an understanding of how to effectively manage mental health distress in a healthy manner and be educated on psychopharmacologic intervention education."

3. Patient A3's Biopsychosocial Assessment dated, 11/04/18, listed the following non-social work discipline recommendations and generic social work recommendations:

"Monitor for safety and change in symptoms, encourage medication compliance and group participation, aftercare planning with case management assistance."

4. Patient A4's Biopsychosocial Assessment, dated 11/20/18, listed the following non-social work discipline treatment recommendations:

"Monitor mental status, safety and behaviors"
"Medications and tx compliance"
"Encourage group participation"

5. Patient A5's Biopsychosocial Assessment, dated 11/13/18, listed non-social work discipline functions as well as generic social work treatment recommendations:

"While patient is on IPU [Inpatient Unit] patient will be encouraged to engage in [his/her] treatment by attending therapeutic groups, meeting with NP [nurse practitioner] and clinician daily, working with clinician to develop a treatment plan. And taking medications as scheduled ..."

6. Patient A6's Biopsychosocial Assessment, dated 11/17/18, listed no treatment recommendations.

7. Patient A7's Biopsychosocial Assessment, dated 11/19/18, listed the following non-social work discipline and generic treatment recommendations:

"While the patient is at High Point Hospital the pt. will be encouraged to partake in groups, engage with [his/her] tx team on a daily basis, verbalize an understanding of the risk factors that prompted placement at High Point Hospital, work with the aftercare team on a discharge plan, verbalize an understanding of how substance use impacts mental health and vice/versa, and be educated on psychopharmacological intervention/education and harm reductions."

8. Patient A8's Biopsychosocial dated, 10/29/18, listed the following non-social work discipline functions and generic social work treatment recommendations:

"Monitor for safety and changes in symptoms, encourage medication compliance and group participation, aftercare planning with case management staff and outside providers."

B. Policy Review

Hospital policy, "Biopsychosocial History and Assessment Policy," HPH & HP/Clinical 041-001-12, revised 7/16, listed the following regarding Biopsychosocial Assessments:

"The goal of the assessment function is to determine appropriate treatment, care and service, the type of treatment, care and services to be provided ..."

C. Interview

In an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management concurred with the findings regarding social work treatment recommendations.

Based on record review, policy review and interview, the facility failed to provide treatment plans that identified patient-related, short-term and long-term goals in observable, measurable, behavioral terms for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the goals were often unrelated to the problems identified and were not measurable. This failure results in a document that does not identify expected treatment outcomes in a manner that can be understood by treatment staff and patients.

Findings Include:

1. Patient A1 was admitted on 11/8/18. The MTP, dated 11/8/18, had for the problem, "Schizophrenia unspecified," the unmeasurable short-term goal, "Decrease anxiety and depression symptoms and increase self-esteem."

2. Patient A2 was admitted on 11/9/18. The MTP, dated 11/9/18, had for the problem, "Psychosis," the unmeasurable short-term goal, "Improve reality testing."

3. Patient A3 was admitted on 11/3/18. The MTP, dated 11/6/18, had for the problem, "Disorganized bxs [behaviors] and thinking," the unmeasurable short-term goal, "Develop understanding of personal symptoms."

4. Patient A4 was admitted on 11/19/18. The MTP, dated 11/19/18, had for the problem, "Anxiety," the non-specific, unrelated short-term goal, "Stabilize mood."

5. Patient A5 was admitted on 11/12/18. The MTP, dated 11/13/18, had for the problem, "No substance abuse history," the unrelated and unmeasurable short-term goal, "Reduce angry behaviors on a monthly basis."

6. Patient A6 was admitted on 11/16/18. The MTP, dated 11/19/18, had for the problem, "Audio hallucinations," the unrelated and unmeasurable short-term goal, "Increase participation in daily social and academic activities while still setting aside time for themselves."

7. Patient A7 was admitted on 11/18/18. The MTP, dated 11/19/18, had for the problem, "Homicidal ideation," the unmeasurable short-term goal, "Reduce angry behavior on a monthly basis."

8. Patient A8 was admitted on 10/27/18. The MTP, dated 10/27/18, had for the problem, "Unspecified Schizophrenia Spectrum," the unrelated and unmeasurable short-term goal, "Client will reflect on past triggers."

B. Policy Review

The hospital policy, "Multidisciplinary Treatment Plan Policy (Provisional/Comprehensive)," 401-705-025-11, revised 7/16, states that nurses and clinicians "Will document short-term goals in patient's own language either in quotes or using the phrase "patient states."

C. Interview

1. During an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management were shown examples of short-term goals pulled from sample patient records. Both agreed that the goals were often unrelated to the problem, non-behavioral and unmeasurable.

2. In an interview on 11/27/18 at 2:00 p.m. the Medical Director agreed that short term goals should be behavioral, observable, and measurable and that the existing goals were not.

Based on record review, policy review and interview, it was determined that the hospital failed to develop treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the interventions were either absent, were generic discipline practice or were unrelated to the identified problems and short-term goals. This failure results in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 11/8/18. The MTP, dated 11/8/18, had for the short-term goal, "Decrease anxiety and depression symptoms and increase self-esteem," the generic nursing intervention, "Patient will take psychiatric medications as prescribed, discuss efficacy and report any side effects."

2. Patient A2 was admitted on 11/9/18. The MTP, dated 11/9/18, had for the short-term goal, "Decrease anxiety symptoms," the generic nursing intervention, "Patient will report to nursing for VS [Vital Signs-temperature, blood pressure and pulse] assessment and medication administration."

3. Patient A3 was admitted on 11/3/18. The MTP, dated 11/6/18, had for the short-term goal, "Develop understanding of personal symptoms," the non-specific intervention, "Psycho- education."

4. Patient A4 was admitted on 11/19/18. The MTP, dated 11/19/18, had for the short-term goal, "Anxiety," the generic nursing intervention, "Medicate as prescribed."

5. Patient A5 was admitted on 11/12/18. The MTP, dated 11/13/18, had for the short-term goal, "Take medications as directed by the physician," the nursing intervention, "Client: Client will adhere to medications order [sic] by physician and report any side effects." This intervention requires the patient to report side effects to the nurse instead of the nurse assessing the patient for side effects. In addition, this intervention is generic discipline practice that nursing would monitor for all patients.

6. Patient A6 was admitted on 11/16/18. The MTP, dated 11/19/18, had no interventions listed for the short-term goal, "Client will implement a weekly schedule that allows them to explore social and academic activities."

7. Patient A7 was admitted on 11/18/18. The MTP, dated 11/19/18, had for the short-term goal, "Reduce angry behaviors on a monthly basis," the unrelated and vague intervention, "Provider: Inpatient Psych [Psychiatric] Unit Daily."

8. Patient A8 was admitted on 10/27/18. The MTP, dated 10/27/18, had no interventions listed for the short-term goal, "Be able to identify symptoms and impact on daily living."

B. Policy Review

The hospital policy, "Multidisciplinary Treatment Plan Policy (Provisional/Comprehensive)," 401-705-025-11, revised 7/16, states, "This individualized written contract [MTP] provides precise, measurable objectives using clearly stated interventions, which are continuously updated to reflect any significant changes."

C. Interview

1. During an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management were shown examples of interventions and agreed that they were sometimes absent, unrelated to the short-term goal or were generic discipline practice.

2. During an interview on 11/27/18 at 2:00 p.m., the Medical Director agreed that existing staff interventions were generic and were not discipline-specific.

Based on medical record review and interview, the hospital failed to ensure that the staff member responsible for each intervention was identified by discipline on the Master Treatment Plan (MTP) in eight of (8) of (8) treatment plans (A1, A2, A3, A4, A5, A6, A7, and A8). This failure has the potential to result in the patient and other staff being unaware of which staff person, by discipline, is responsible for the intervention being implemented and documented.

Findings Include:

A. Medical Records

1. Patient A1's MTP, dated 11/8/18, failed to identify the disciplines of all those persons participating in the treatment plan.

2 Patient A2's MTP, dated 11/9/18, failed to identify the disciplines of all those persons participating in the treatment plan.

3. Patient A3's MTP, dated 11/6/18, failed to identify the disciplines of all those persons participating in the treatment plan.

4. Patient A4's MTP, dated 11/19/18, failed to identify the disciplines of all those persons participating the treatment plan.

5. Patient A5's MTP, dated 11/13/18, failed to identify the disciplines of all those persons participating in the treatment plan.

6. Patient A6's MTP, dated 11/19/18, failed to identify the disciplines of all those persons participating in the treatment plan.

7. Patient A7's MTP, dated11/19/18, failed to identify the disciplines of all persons participating in the treatment plan.

8. Patient A8's MTP, dated 10/27/18, failed to identify the disciplines of all persons participating in the treatment plan.

B. Interviews:

1. During an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management concurred with the findings regarding the lack of discipline identification on the MTPs.

2. During an interview on 11/27/18 at 2:00 p.m., the Medical Director concurred with the findings regarding the lack of documentation of staff disciplines on the MTPs.

Based on record review, observation, and interviews, the facility failed to ensure that active treatment measures, such as group and/or individual treatment were provided for six (6) of eight (8) active sample patients (A1, A2, A5, A6, A7, and A8) who were unwilling, unable, or not motivated, to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

Findings Include:

A. Specific Patient Findings

1. Patient A1 was admitted on 11/8/18. The Psychiatric Evaluation, dated 11/9/18, revealed the patient was admitted due to confusion and disorientation. S/he had hit someone in the head with a fire extinguisher while in the group home.

Review of Patient A1's MTP, dated 11/8/18, revealed no short-term goals or interventions related to group attendance. Unit 1 Group Schedule revealed that 10 groups were scheduled per day. Review of information provided by the Quality Improvement/Risk Manager (QI/RM) on 11/28/18 revealed that Patients A1 did not attend any groups scheduled from 11/13/18 -11/27/18. The MTP did not address Patient A1's failure to attend groups and did not provide guidance for alternative treatment.

During an interview on 11/26/18 at 1:35 p.m., Patient A1 had to be retrieved from his/her room to come to the interview. S/he indicated to the surveyor that s/he did not attend groups. S/he answered all other questions with, "I don't know."

During an observation on Unit 1 on 11/26/18 at 1:40 p.m., two (2) of the 11 patients on the unit were observed attending the Social Skills Group. Patient A1 did not attend the group and was in the bedroom.

During an interview on 11/26/18 at 1:45 p.m., RN1 stated that Patient A1 isolated in the room most the time. Although RN1 attempted to talk to the patient and attempted to have the patient engage in treatment activities, s/he stated that attempts were mostly unsuccessful.

During an observation on Unit 1 on 11/27/18 at 10:20 a.m., eight (8) patients were observed in a Relapse Prevention Group on Unit 1. Patient A1 did not attend.

2. Patient A2 was admitted on 11/9/18. The Psychiatric Evaluation, dated 11/9/18, revealed that the patient was admitted due to delusional thinking, believing s/he had a chip in his/her head, and running out of his/her house with no clothes on. S/he was reportedly responding to internal stimuli.

Review of Patient A2's MTP, dated 11/11/18, revealed the Objective, "Attend at least two groups daily." Unit 1 Group Schedule revealed that 10 groups were scheduled per day. Review of information provided by the Quality Improvement/Risk Manager (QI/RM) on 11/28/18, revealed that Patient A2 had attended none of the groups offered between 11/13/18 and 11/27/18. The MTP did not address Patient A2's failure to attend groups and did not provide guidance for alternative treatment.

During an interview on 11/26/18 at 1:25 p.m., Patient A2 was asked to leave his/her room to come to the interview. S/he emphatically stated that s/he never went to groups nor did s/he intend to do so. In addition, s/he further stated that s/he was not taking any medication, nor did s/he intend to do so. Upon being questioned about this, s/he went on to state there was no reason to take medications as there were no problems. His/her only goal was to be discharged.

During an observation on 11/26/18 at 1:40 p.m., only 2 of the 11 patients on Unit 1 attended the Social Skills Group. Patient A2 did not attend the group and was in the bedroom.

During an interview on 11/26/18 at 1:45 p.m., RN1 confirmed that Patient A2 neither attended groups nor was s/he taking any medications. RN1 further stated that medications could not be forced since the patient was not exhibiting disruptive behavior other than treatment refusals.

During an observation on 11/27/18 at 10:20 a.m., eight (8) patients were observed in a Relapse Prevention Group on Unit 1. Patient A2 did not attend the group.

During an interview on 11/27/18 at 2:00 p.m., the Medical Director concurred that this patient was not receiving active treatment.

3. Patient A5 was admitted on 11/12/18. The Psychiatric Evaluation, dated 11/13/18, revealed that the patient was admitted due to taking gasoline into his/her residential program and threatening to kill others.

Review of Patient A5's MTP, dated 11/15/18, showed only one intervention related to groups, and that was the nursing intervention, "Offer different support groups and skills." Unit 3, "Group Schedule," revealed that nine groups were scheduled each day. Review of information provided by the Quality Improvement/Risk Manager (QI/RM) on 11/28/18, revealed that Patient A5 had attended 25 of the 135 groups scheduled from 11/13/18-11/27/18. The MTP did not address Patient A5's failure to attend groups and did not provide guidance for alternative treatment.

During observation on Unit 3 from 10:00 a.m.-11:00 a.m. on 11/27/18, it was determined that two of ten patients attended the Community Meeting/Goals group that occurred from 9:30 a.m.-10:30 a.m. Patient A5 did not attend and was in his/her room in bed. Observation of the Nutrition Group that was scheduled for 10:30 a.m.-11:15 a.m., revealed two of ten patients in attendance. Patient A5 did not attend and was in his/her room in bed.

During interview on 11/27/18 at 10:15 a.m., Mental Health Specialist 4 (MHS4) stated, "On rainy days like today, the patients like to go back to bed after breakfast." During interview on 11/27/18 at 10:45 a.m., Patient A5 stated that s/he did not go to many groups and did not need hospital level of care.

4. Patient A6 was admitted on 11/16/18. The Psychiatric Evaluation, dated 11/16/18, revealed that the patient was admitted from assisted living for aggression and hallucinations.
Review of the MTP, dated 11/19/18 showed no interventions related to groups. Unit 2 Group Schedule revealed that 10 groups were scheduled per day. Review of information provided by the QI/RM on 11/28/18, revealed that Patient A6 had attended none of the 100 groups scheduled from 11/18/18-11/27/18. The MTP did not address Patient A6's failure to attend groups and did not provide guidance for alternative treatment.
Observations on Unit 2 on 11/26/18 from 1:30 p.m.-3:30 p.m., and on 11/27/18 from 9:00 a.m.-10:00 a.m. and 1:00 p.m. - 2:00 p.m., revealed that Patient A6 was in his/her room and refused to come out to attend groups. Observations on 11/26/18 at 1:45 p.m., revealed 3 out of 21 patients on the unit were in attendance in the Dialectical Behavior Therapy group (DBT-A type of therapy for patients with mood disorder and those who need to change patterns of behavior that are not helpful.) The same three patients were observed in the 2:45 p.m. "Introduction to Recovery" group. The remaining 18 patients were either in their rooms, asleep in bed, or sitting in the dayroom.
During interview on 11/26/18 at 1:30 p.m., LPN6 stated that Patient A6 "self isolates" and "Is afraid to come out of [his/her] room."

During interview on 11/26/18 at 2:00 p.m., Patient A6 shook his/her head, "no," when asked if s/he attended group.

5. Patient A7 was admitted on 11/18/18. The Psychiatric Evaluation, dated 11/18/18, revealed that the patient was admitted for homicidal ideation.

Review of the MTP, dated 11/19/18, showed the only mention of group as, "Attend AA/NA meetings weekly." This meeting was not listed on the weekly schedule. Unit 2 Group Schedule revealed that 10 groups were scheduled per day. Review of information provided by the QI/RM on 11/28/18, revealed that Patient A7 had attended 18 of the 100 groups scheduled from 11/18/18-11/27/18. The MTP did not address Patient A7's failure to attend groups and did not provide guidance for alternative treatment.

Observations on Unit 2 on 11/26/18 from 1:30 p.m.-3:30 p.m. revealed that patient A7 was in bed and did not attend the 1:30 p.m. DBT group or the 2:45 p.m., Introduction to Recovery group. Patient A7 was observed in the dayroom eating lunch at 3:00 p.m. Observations on 11/27/18 from 9:00 a.m.-10:00 a.m. revealed that patient A7 was in his/her room and that the scheduled MHS group, Leisure Activity, was not being held as scheduled.

During interview on 11/26/18 at 3:00 p.m., Patient A7 stated that s/he spent most of his/her time in the dayroom or bedroom. Patient A7 stated that s/he didn't go to all the groups.

6. Patient A8 was admitted on 10/27/18. The Psychiatric Evaluation dated 10/27/18, revealed the patient was admitted for suicidal ideation and auditory hallucinations.

Review of the MTP, dated 10/27/18, showed as the only mention of group interventions, "Individual and group therapies." Unit 2 Group Schedule revealed that 10 groups were scheduled per day. Review of information provided by the QI/RM on 11/28/18, revealed that Patient A8 had attended 12 of the 135 groups scheduled from 11/13/18-11/27/18. The MTP did not address Patient A8's failure to attend groups and did not provide guidance for alternative treatment.

Observations on Unit 2 on 11/26/18 from 1:30 p.m.-3:30 p.m. revealed that patient A8 was in the dayroom and did not attend the 1:30 p.m. DBT group or the 2:45 p.m., Introduction to Recovery group. Observations on 11/27/18 from 9:00 a.m.-10:00 a.m. revealed that patient A7 was in his/her room and that the scheduled MHS group, Leisure Activity, was not being held as scheduled.

During an interview on 11/26/18 at 1:35 p.m., RN4 revealed that Patient A8, "Doesn't usually go to groups. S/he usually just sits."

During an interview on 11/26/118 at 1:45 p.m., Patient A8 stated that the activity daily schedule was not followed, and groups didn't always occur. S/he also stated, "I don't like groups and they can't force us to go."

B. Interviews

1. During an interview on 11/26/18 at 1:35 p.m., RN4, when asked which patients on Unit 2 did not go to group, laughed and said, "At least half don't go to group."

2. During an interview on 11/26/18 at 3:00 p.m., MHS3, when asked why so few patients were in group, answered, "Groups are optional."

3. During an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director QI/RM acknowledged their awareness of the lack of attendance in groups.

Based on medical record review and interview the facility failed to ensure that patient discharge summaries contained a summary of the individualized patient's condition on discharge for two (2) of eight (8) discharged patients (D4 and D5). This failure hinders the information available to aftercare providers, thus potentially impacting the treatment after discharge.

Findings Include:

A. Medical Records

1. Patient D4's discharge summary, dated 10/24/18, and Patient D5's discharge summary, dated 10/26/18, contained identical non-individualized information in the discharge section named "Condition on Discharge and Prognosis." Both patients were described as, "Alert oriented x 3, fairly groomed, Mood: hopeful but anxious. Insight and judgement are fair. Energy level: moderate. Sleep and appetite good. No overt signs of psychosis. Denies suicidal ideations or homicidal ideations."

Interview:

1. In an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management concurred with the findings regarding the lack of individualization in these two patients' condition on discharge.

2. In an interview on 11/27/18 at 2:00 p.m. the Medical Director concurred that Patient D4 and D5's "condition on discharge" were written in identical terms and were not individualized.

Based on record review, document review and interview, the Medical Director failed to ensure:

1. The provision of treatment plans that identified patient-related short-term and long-term goals in observable, measurable, behavioral terms for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the goals were often unrelated to the problem and were not measurable. This failure results in a document that does not identify expected treatment outcomes in a manner that can be understood by treatment staff and patients. (Refer to B121)

2. The development of treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Specifically, the interventions were either absent, were generic discipline practice, or were unrelated to the identified problem and short-term goal. This failure results in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122)

3. That the staff member responsible for each intervention was identified by discipline on the Master Treatment Plan (MTP) for eight (8) of eight (8) treatment plans (A1, A2, A3, A4, A5, A6, A7 and A8). This failure has the potential to result in the patient and other staff being unaware of which staff person, by discipline, is responsible for the intervention being implemented and documented. (Refer to B123)

4. That active treatment measures, such as group and/or individual treatment were provided for -six (6) of eight (8) active sample patients (A1, A2, A5, A6, A7, and A8) who were unwilling, unable, or not motivated to attend or participate in active treatment groups. The Master Treatment Plans (MTPs) for these patients failed to address the patient's lack of participation or to include alternative interventions. Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125)

5. That patient discharge summaries contained a summary of the individualized patient's condition on discharge for two (2) of eight (8) discharged patients (D4 and D5). This failure hinders the information available to aftercare providers, thus potentially impacting the treatment after discharge. (Refer to B135)

Interview

In an interview on 11/2718 at 2:00 p.m., the Medical Director concurred with findings regarding short term goals, interventions, staff disciplines, discharge summaries, as well as lack of active treatment.

Based on record review and interview, the Director of Nursing failed to:
l. Ensure that nursing interventions listed on patients' MTPs addressed individualized patient needs for four (4) of eight (8) active patients (A1, A2, A4, and A5). Instead, the interventions were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient-specific nursing interventions. This deficiency results in a failure to guide nursing staff regarding the specific treatment purpose of each intervention and limits the therapeutic nursing interventions available to patients.

ll. Ensure that the discipline of nursing staff responsible for specific aspects of care was listed on the MTPs of four (4) of eight (8) active sample patients (A1, A2, A4, and A5). This practice makes it difficult for patients and staff to know that a Registered Nurse is responsible for specific interventions. (Refer to B123)

Findings Include:

l. Nursing Interventions

1. Patient A1 was admitted on 11/8/18. The MTP, dated 11/8/18, had for the short-term goal, "Decrease anxiety and depression symptoms and increase self-esteem," the generic nursing intervention, "Patient will take psychiatric medications as prescribed, discuss efficacy and report any side effects."

2. Patient A2 was admitted on 11/9/18. The MTP, dated 11/9/18, had for the short-term goal, "Decrease anxiety symptoms," the generic nursing intervention, "Patient will report to nursing for VS [Vital Signs-temperature, blood pressure and pulse] assessment and medication administration."

3. Patient A4 was admitted on 11/19/18. The MTP, dated 11/19/18, had for the short-term goal, "Anxiety," the generic nursing intervention, "Medicate as prescribed."

4. Patient A5 was admitted on 11/12/18. The MTP, dated 11/13/18, had for the short-term goal, "Take medications as directed by the physician," the nursing intervention, "Client: Client will adhere to medications order [sic] by physician and report any side effects." This intervention requires the patient to report side effects to the nurse instead of the nurse assessing the patient for side effects. In addition, this intervention is generic discipline practice that nursing would monitor for all patients.

C. Interviews

1. During an interview on 11/27/18 at 9:00 a.m., the Clinical Director and the Director of Quality Improvement/Risk Management (QI/RM) were shown examples of nursing interventions, and they agreed that they were sometimes absent or unrelated to the short-term goal or were generic nursing discipline practice. In addition, they acknowledged that nursing was often not identified by discipline on the MTPs.

2. During an interview on 11/28/18 at 9:15 a.m., the Director of Nursing agreed that the nursing interventions on the MTPs were sometimes absent or unrelated to the short-term goal or were generic nursing discipline practice. In addition, they acknowledged that nursing was often not identified by discipline on the MTP.

Based on document review and interview, the facility failed to assess the rehab therapy needs of admitted patients and failed to provide an activity therapy program with an appropriate variety of services offered by qualified staff for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) and all other patients in the facility. Failure to have patient assessments and therapeutic activity programming denies the patients an opportunity to learn leisure and educational skills that could be helpful when discharged.

Findings Include:

A. Medical Records

1. Review of the medical records for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) revealed that none of the patients had assessments to determine their therapeutic activity and leisure needs.

2, Review of the Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) revealed that there were no Rehabilitation (Rehab) staff signatures on the plans and no interventions assigned to Rehab Therapy staff. Although there were no interventions assigned, the Rehab staff conducted five groups on each unit per day. The groups were primarily educational in nature and did not include recreational or leisure activities.

B. Document Review

1. Review of the resumes for the five (5) full-time and one (1) part-time staff in the Rehab Department revealed that only the part-time staff member had any rehab educational preparation and that was as an Occupational Therapist (OT). The Clinical Director, who oversees Rehab Services, has a counseling degree. The educational preparations for the full-time staff included degrees in Psychology (2 staff), Audio and Media Technology, Criminal Justice, and Social Work.

C. Interviews

1. During an interview on 11/27/18 at 2:00 p.m., the Clinical Director acknowledged that although all of the rehab staff had bachelor's degrees, none of the full-time staff had received training or education in a Rehab Therapy field, such as Recreational Therapy, Speech Therapy, Music Therapy or Occupational Therapy. The Clinical Director further acknowledged that the Rehab staff did not complete Rehab assessments on patients and did not attend Treatment Team meetings. The Treatment Team meetings are held in the mornings and the Rehab staff don't come to work until 1:30 p.m.

2. During an interview on 11/28/18 at 11:15 a.m., the Hospital Administrator stated that the part-time Occupational Therapist does not offer oversight or consultation to the other Rehab staff and has no supervisory accountability.