HospitalInspections.org

Based on review of Medical Staff Bylaws, Rules and Regulations, credentialing file review and medical record reviews, the hospital's medical staff failed to ensure patient care was provided in accordance with the privileges granted for 1 of 1 midlevel provider (NP #1) credentialing file reviewed for 8 of 20 sampled medical records reviewed (#14; #20; #18; #19; #17; #7; #8; and #3).

The findings included:

Review of the "2019 Medical Staff Bylaws, Rules and Regulations" revealed "... The facility will admit (by order of the staff physician) patients suffering from all types and psychiatric illness. Patients may be treated by clinicians who have submitted proper credentials and have been duly appointed to membership of the Medical Staff, or who are receiving temporary privileges, in accordance with the bylaws. ... Each patient, on admission, is to have a psychiatric evaluation including a mental status evaluation and a complete medical history and physical examination accomplished. Both documents must be completed within twenty-four (24) hours of the patient's admission. ... Nurse Practitioners (NPs) or Physician Assistants (PAs) may participate in or complete the Psychiatric Evaluation and/or History and Physical, as allowed by the Hospital's State Scope of Practice requirements and, as credentialed to perform same by the Hospital's Medical Staff. ... Membership to the medical staff includes only those clinical privileges and prerogatives granted to the member by the Governing Board in accordance with these bylaws. ... Each application and reapplication must include a completed form specifically delineating the clinical privileges desired by the applicant. ..."

Review of NP #1's credentialing file revealed the nurse practitioner was licensed as a "Adult Geriatric Nurse Practitioner (AGNP)" with an issue date of 11/29/2019 and expiration date of 11/30/2019. Review of NP #1's application and work history revealed NP #1 had worked in an acute hospital setting since becoming a nurse in December 2013. Review revealed the Nurse Practitioner had worked at an eating disorder hospital from October 2018 until January 2019. Review of the "Specialty of Nurse Practitioner Delineation of Privileges" form revealed "Primary Care Core Nurse Practitioner Privilege; Privileges include but not limited to: Perform history and physical; Apply, remove and change dressing and bandages; Counsel and instruct patients, families and caregivers as appropriate; Direct care as specified by medical staff approved protocols; Initiate appropriate referrals; Make rounds on patients; Order and initial interpretation of diagnostic testing and therapeutic modalities, such as laboratory tests, medications, hemodynamic monitoring, treatments, x-ray, EKG, IV fluids and electrolytes, etc.; Record progress notes." Review of the "Psychiatric and Mental Health Nurse Practitioner Privilege; Privileges include but are not limited to: Perform comprehensive psychiatric evaluation ..." Review of the file revealed NP #1 requested privileges on 01/27/2019 for "Nurse Practitioner Core" for "Adolescents and Adults (13 & above)"; "Adults (18 & above)"; and "Geriatrics (55 & above)." Review of the "Speciality of Nurse Practitioner Delineation of Privileges" form revealed another line to request privileges for "Nurse Practitioner Core (Psychiatric)" that was left blank. Review revealed the Medical Director and Governing Board approved the "Nurse Practitioner Core" privileges on 02/26/2019. Review of a letter dated 02/26/2019 from the hospital's Chief Executive Officer (CEO) revealed a recommendation for approval for a two-year period with clinical privileges as an "Nurse Practitioner / Adult Gerontology."

1. Review of Patient #14's open medical record revealed a 16 year-old female admitted under petition for involuntary commitment (IVC) on 11/18/2019 for suicidal ideations, major depressive disorder and substance abuse. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/19/2019 at 1100 by NP #1 and cosigned by MD #2 on 11/19/2019.

Telephone interview on 11/21/2019 at 1028 with the Director of Credentialing and Privileging revealed the staff member was responsible for collecting and verifying all the credentialing paperwork for appointment and privileging. Interview revealed the staff member is located out of state and maintainers a "tangible file" on the medical staff. Interview revealed once the paperwork has been verified, the file information is sent to the hospital staff. Interview revealed hospital staff on site handle the meeting approval process. The staff member reviewed NP #1's file and reported she requested NP Core Privileges for adolescent, adult and geriatric patients. Interview revealed NP #1 did not request privileges as a psychiatric nurse practitioner and was not privileged to perform comprehensive psychiatric evaluations. The staff member stated "She is not Board Certified in Psychiatry. She is not a Psychiatric Nurse Practitioner. She is certified as an Adult Gerontology Nurse Practitioner. She will not be able to do those privileges listed for psychiatric nurse practitioner. She should not be practicing in that area." Interview revealed NP #1 was board certified December 14, 2018 as a Gerontology Nurse Practitioner.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnosed, assessed and educated the patients. Interview revealed NP #1 is on call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

2. Review of Patient #20's open medical record revealed a 14 year-old female admitted under petition for involuntary commitment (IVC) on 11/10/2019 for suicidal ideations, bipolar disorder verses major depressive disorder and post traumatic stress disorder (PTSD). Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/11/2019 at 1030 by NP #1 and cosigned by MD #2 on 11/11/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

3. Review of Patient #18's open medical record revealed a 16 year-old female admitted under petition for involuntary commitment (IVC) on 11/14/2019 for suicidal ideations and bipolar disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/15/2019 at 1000 by NP #1 and cosigned by MD #2 on 11/15/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

4. Review of Patient #19's open medical record revealed a 17 year-old female admitted as a voluntary admission on 11/19/2019 for suicidal ideations and bipolar disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/20/2019 at 1000 by NP #1 and cosigned by MD #2 on 11/20/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

5. Review of Patient #17's open medical record revealed a 16 year-old female admitted as a voluntary admission on 11/17/2019 for suicidal ideations and major depressive disorder. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 11/18/2019 at 1100 by NP #1 and cosigned by MD #2 on 11/18/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.



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6. Review of Patient #7's closed medical record revealed a 13-year-old female admitted under petition for involuntary commitment (IVC) on 09/20/2019 for suicidal ideations. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 09/20/2019 at 1600 by NP #1 and cosigned by MD #2 (not dated).

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

7. Review of Patient #8's closed medical record revealed a 13-year-old female admitted under petition for involuntary commitment (IVC) on 09/20/2019 for suicidal ideations. Review of the Comprehensive Psychiatric Evaluation revealed it was completed on 09/20/2019 at 1500 by NP #1 and no Physician cosigned.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.



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8. Review of Patient #3's closed medical record revealed a 17 year old female admitted under petition for involuntary commitment on 09/10/2019 for Suicidal Ideations with ingestion of several Zoloft (antidepressant) pills. Review of a Comprehensive Psychiatric Evaluation revealed the document was completed on 09/11/2019 at 1200 by NP #1 and cosigned by MD #2 on 09/11/2019.

Interview on 11/21/2019 at 1500 with NP #1 revealed she stated working at the hospital on 02/28/2019 as a nurse practitioner. Interview revealed she was responsible for the psychiatric care of adolescent female patients years 13 and above on the 100 and 200 halls of the hospital. Interview revealed the NP managed medications and treatment for her assigned patients. Interview revealed NP #1 completed the comprehensive psychiatric evaluations of her assigned patients on admission, performed daily rounds, adjusted medications, diagnose, assess and educate the patients. Interview revealed NP #1 takes call one week every month and is responsible for the whole hospital. Interview revealed another psychiatrist would be called if there were needs for a 12 year-old patient. Interview revealed MD #2 was available for consult when needed. NP #1 reported her privileges were defined in her collaborative practice agreement and that the agreement covered her for the things that she was doing. NP #1 stated she was not sure what hospital privileges were delineated for her.

Interview on 11/22/2019 at 1100 with MD #2 revealed the psychiatrist started around the same time as NP #1 and that he worked closely with her. Interview revealed MD #2 and NP #1 discuss all cases and that MD #2 may not see all of the patients on NP #1's case load. MD #2 stated "New patients are discussed and I sign off on them. I discuss all cases. I may or may not see the patients on her case load. Difficulty of treatment determines when I go to see them. New admits, depends on when they get admitted. I do the 800 hall (adolescent boys). She does the 100/200 hall. She will do the (comprehensive psychiatric) assessment. We discuss treatment and I sign off. I have a pretty decent understanding of the patients on site." Interview with MD #2 revealed he was not aware that NP #1's delineation of privileges failed to include completing comprehensive psychiatric evaluations.

Telephone interview with MD #3 on 11/21/2019 at 1435 revealed he was the Medical Director of the acute hospital and he was the supervising physician for NP #1. Interview revealed there were two types of mid-level practitioners that worked at the hospital. MD #3 reported most of the nurse practitioners managed the medical needs for their patients and NP #1 was the only mid-level that managed the psychiatric needs. Interview revelaed NP #1 has functioned in that role since she started here. The physician stated he initially had meetings with her and reviewed her paperwork weekly for the first month, then monthly for four months. Interview revealed they are now meeting annually. MD #3 stated MD #2 is available and consults with NP #1 when needed. When asked about NP #1's privileges, MD #3 stated he was not aware that she had requested and been approved NP Core Privileges. MD #3 stated that he was not aware that NP #1 was not privileged to perform comprehensive psychiatric evaluations or manage the psychiatric patient needs. MD #3 stated "I don't understand that at all. That is an unfortunate mistake."

Based on review of policies, medical records, personnel files, and interviews with staff, the facility failed to train and educate nursing staff to provide care to a Diabetic patient on an Insulin pump for 1 of 1 sampled diabetic patient. (Patient #2).

The findings include:

Review of policy titled "Admission and Exclusion Criteria" with revision date of 01/30/2019 revealed "...5. Examples of medical conditions that would need to be assessed individually to determine appropriateness for admission to the psychiatric program are: ...5.1.2 Patients who are insulin dependent with unstable blood sugars or who have an insulin pump...."

Review of a Psychiatric Evaluation dated 08/31/2019 at 1556 revealed Patient #2, a 13 year-old female was received as a transfer from local hospital after admission for concerns of SI with plan (Suicide ideations--thoughts of suicide with plan to complete using insulin to overdose), explosive anger, and intrusive thoughts of violent acts including choking her sister and shooting the assistant principal. "Pt admitted SI with plan to OD on insulin everytime she changes out cartridge for insulin pump but has been inconsistent with reports of timeline d/t (due to) memory problems." Review of Admission orders dated 08/31/2019 at 1450 revealed "Pt can use insulin pump and glucose monitoring system during admission. Close observation while awake (due to insulin pump). Pt is allowed to wear glucose monitoring system/keep in pockets while awake..."

Review of a "24 hour Registered Nurse Daily Mental Status Assessment" dated 08/31/2019 at 1340 written by RN #17, revealed "...Sugars have been running high and patient received insulin (Novolog) for coverage....Parents will bring insulin pump...1800 BS 189. pt used Glucose system to administer 8 units of Novolog insulin via pump. FYI: 1630. FS (finger stick blood sugar) 59. 8 ounces of juice (orange and Apple) 1 bag of chips. 1700 FS 79." 08/31/2019 at 2105 revealed "...BG (Blood Glucose) 247. Pt (Patient received 2 units of Novolog via pump." At 2115, BG 284--Pt gave 2 units of Novolog--reports she has 1.6 units 'on board.'" At "2230, BG 243. Finger stick performed. Pt thinks the machine is malfunction BG read 191--Pt programmed the machine. Reports she has 1.65 on board as per the machine, and pt did not need insulin coverage at this time." At 0100, BG 58. Pt denies symptoms. Gave Pt 8 Fl. (fluid) oz (ounces) orange juice."

Interview on 11/21/2019 at 1345 with RN #17 revealed working with this patient's pump was the first one here at this facility. Interview revealed RN #17 has not received any education on insulin pump while employed at this facility. Interview revealed the insulin was administered to Patient #2 using the results on the insulin pump. Interview revealed the facility's glucometer was not used to double-check the results of the fingerstick.

Interview on 11/21/2019 at 1345 with the Director of Pharmacy revealed the facility should not accept patients with insulin pumps. Interview revealed the safety risk of the insulin pump can be a problem.

Based on closed medical record reviews and staff interviews the physician failed to include in the psychiatric evaluation an inventory of the patient's assets in 2 of 16 patients reviewed (#12 and #1).

The findings included:

1. Open medical record for Patient #12 revealed a 15 year-old male admitted on 11/10/2019 under petition for involuntary commitment with major depressive disorder. Review of the comprehensive psychiatric evaluation documented by MD #2 on 11/11/19 at 1040 revealed a section for documentation of "Patient Assets/Strengths (provide 2 or more - must be able to develop a treatment plan around) and weaknesses:" Review of the section revealed the area for strengths (assets) was left blank with no evidence of an assessment of the patient's assets documented.

Interview on 11/22/2019 at 1600 with MD #2 revealed there was no documentation of assets available. The interview revealed the patient's assets were used to develop the patient's individualized treatment plan and they should have been documented.



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2. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with Mood Disorder. Review of the comprehensive psychiatric evaluation documented by MD #2 on 08/02/2019 at 1000 revealed a section for documentation of "Patient Assets/Strengths (provide 2 or more - must be able to develop a treatment plan around) and weaknesses:" Review of the section revealed the area for strengths (assets) was left blank with no evidence of an assessment of the patient's assets documented.

Interview on 11/22/2019 at 1600 with MD #2 revealed there was no documentation of assets available. The interview revealed the patient's assets were used to develop the patient's individualized treatment plan and they should have been documented.

Based on review of the facility policy, medical record review and staff interview, facility staff failed to ensure an individualized comprehensive treatment plan that included behavioral health and medical needs was reviewed with the patient or legal guardian for 4 of 16 sampled patients (#2, #3, #6, #7).

The findings included:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. Patients are involved in the treatment planning process and sign their treatment plans. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... The patient's involvement and understanding of the interdisciplinary person centered treatment plan should be indicated by his/her signature or a family member's if the patient is unable to do so. ... Specific services that are identified for medically fragile patients will be noted in the person centered treatment plan."

1. Review of a closed medical record on 11/19/2019 revealed Patient #2 was a 13 year-old female admitted to the hospital on 08/30/2019 for suicide ideation (thoughts of killing self). Review of History and Physical dated 08/31/2019 at 1654 revealed "History of Present Illness: ...13 year old female IVC...w (with) history of ...DM I (Diabetes 1--autoimmune disease requiring insulin)." Review of the discharge summary dated 09/09/2019 revealed "...the patient is Type 1 diabetic and has an insulin pump...." Review of the Interdisciplinary Treatment Plan dated 08/31/2019 of "PROBLEM LIST: (to include psychiatric and medical as identified)" revealed "08/31/2019: Problem 1--Danger to self and others." Review revealed no documentation of the medical diagnosis of Type 1 Diabetes. Review of Patient #2's "Interdisciplinary Treatment Plan" developed by the facility staff on 09/02/2019 revealed the statement "PATIENT/FAMILY INVOLVEMENT: This treatment plan has been presented to and reviewed with the patient and/or family member(s). This patient and family member(s) have been given the opportunity to ask questions and make suggestions." Review revealed below the statement there was a space to record "Patient Signature" and a space to record "Family Signature (if applicable)." Review failed to reveal documentation of a signature for Patient #2 or a family member.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed medical problems should be identified and included on the patient's treatment plan. Interview revealed the treatment plan for Patient #2 failed to include management of the patient's diabetes. Interview revealed patients and legal guardians should be included in treatment planning. Interview revealed the master treatment plans should have been discussed and signed by the patient and legal guardian. Interview confirmed the signatures were blank.

2. Review of a closed medical record on 11/19/2019 revealed Patient #3 was a 17 year-old female admitted to the hospital on 09/10/2019 for suicide ideation (thoughts of killing self). Review of the History and Physical dated 09/11/2019 at 1845 revealed "IMPRESSIONS: MDD (Major depressive disorder), Cystic Fibrosis (genetic disorder that affects mostly the lungs...issues include difficulty breathing and coughing up mucus as a result of frequent lung infections...." Review of the Interdisciplinary Treatment Plan dated 09/11/2019 of "PROBLEM LIST: (to include psychiatric and medical as identified): revealed "09/11/2019: Problem 1--Danger to self." Review revealed no documentation of the medical diagnosis of Cystic Fibrosis. Review of Patient #3's "Interdisciplinary Treatment Plan" developed by the facility staff on 09/11/2019 revealed the statement "PATIENT/FAMILY INVOLVEMENT: This treatment plan has been presented to and reviewed with the patient and/or family member(s). This patient and family member(s) have been given the opportunity to ask questions and make suggestions." Review revealed below the statement there was a space to record "Patient Signature" and a space to record "Family Signature (if applicable)." Review failed to reveal documentation of a signature for Patient #3.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed patients and legal guardians should be included in treatment planning. Interview revealed the master treatment plan should have been discussed and signed by the patient. Interview confirmed the area for the patient's signature was blank.



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3. Review of a closed medical record on 11/19/2019 revealed Patient (Pt) #6 was a 17 year-old female admitted to the hospital on 09/20/2019 for suicide ideation (thoughts of killing self). Review of Pt #6's "Interdisciplinary Treatment Plan" developed by the facility staff on 09/20/2019 revealed the statement "PATIENT/FAMILY INVOLVEMENT: This treatment plan has been presented to and reviewed with the patient and/or family member(s). This patient and family member(s) have been given the opportunity to ask questions and make suggestions." Review revealed below the statement there was a space to record "Patient Signature" and a space to record "Family Signature (if applicable)." Review failed to reveal documentation of a signature for Pt #6 or a family member.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed patients and legal guardians should be included in treatment planning. Interview revealed the master treatment plans should have been discussed and signed by the patient and legal guardian. Interview confirmed the signatures were blank.



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3. Review of Patient #7's closed medical record revealed a 13-year-old female admitted under petition for involuntary commitment on 09/20/2019 at 0951 for suicidal ideation. Review of the Interdisciplinary Treatment Plan revealed it was started on 09/20/2019 at 2255 and completed on 09/23/2019 at 1700. Review revealed the section "... Patient/Family Involvement: This treatment plan has been presented to and reviewed with the patient and/or family member(s). The patient and family member(s) have been given the opportunity to ask questions and make suggestions ..." did not have a signature of the patient nor of the patient's family.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed patients and legal guardians should be included in treatment planning. Interview revealed the master treatment plans should have been discussed and signed by the patient and legal guardian. Interview confirmed the signatures were blank.

Based on review of the facility policy, medical record review and staff interview, facility staff failed to ensure an individualized comprehensive treatment plan was based on the patient's strengths and disabilities in 1 of 16 sampled patients (Patient #1)

The findings include:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. Patients are involved in the treatment planning process and sign their treatment plans. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan...."

Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" dated 08/01/2019 revealed the plan included one identified problem of "Danger to others". Review revealed no documented substantiated diagnosis. Review also revealed no documentation of patient strengths or weaknesses. Review revealed no therapy services interventions or short-term goals were documented for the identified problem. Review revealed the patient was discharged on 11/09/2019 (100 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to be reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.

Based on policy review, medical record review and staff interview the facility failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan for 2 of 16 sampled patients. (Patient #1 and #10)

The findings included:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ...

1. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" revealed no documented substantiated diagnosis. Space left blank. Review of the psychiatric evaluation completed on 08/02/2019 at 1000 revealed a diagnosis of mood disorder. Review revealed the patient was discharged on 11/09/2019 (100 admission days) with discharge diagnoses of schizoaffective disorder-bipolar type II, PTSD, Cognitive Impairment and THC use (substance abuse) Disorder.

Interview on 11/22/2019 at 1440 with Therapist #6 revealed interventions and goals should have been documented. Interview revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.

Interview on 11/19/2019 at 1540 with the Director of Clinical Services revealed the purpose of the treatment team meeting was to discuss and finalize the patient's treatment plan. Interview revealed the plan is updated every seven days. Interview revealed short-term goals should include a target date. The staff member stated "Treatment plans are useless pieces of paper." Additional interview on 11/22/2019 at 1610 with the Director of Clinical Services revealed the treatment plan for acute patients that are admitted to the hospital was to "remove the danger to self and others" and that there are similarities in goals and target dates for all acute patients. The staff member stated "We remove the dangerousness so patients can seek outpatient therapy. Treatment planning is not for me. It serves a purpose for external folks like yourself more than it does for the patient."

2. Open medical record for Patient #10 revealed a 16 year-old male admitted on 11/17/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" dated 11/17/2019 revealed "Danger to Other" as the substantiated diagnosis. Review of the psychiatric evaluation completed on 11/18/2019 at 1616 revealed a diagnosis of major depressive disorder.

Interview on 11/22/2019 at 1440 with Therapist #6 revealed diagnosis are obtain from the psychiatric evaluation and utilized on the treatment plan. Therapist #6 reviewed Patient #10 medical record and confirmed "Danger to other" was not the substantiated diagnosis documented on the patient's psychiatric evaluation.

Interview on 11/19/2019 at 1540 with the Director of Clinical Services revealed the purpose of the treatment team meeting was to discuss and finalize the patient's treatment plan. Interview revealed the plan is updated every seven days. Interview revealed short-term goals should include a target date. The staff member stated "Treatment plans are useless pieces of paper." Additional interview on 11/22/2019 at 1610 with the Director of Clinical Services revealed the treatment plan for acute patients that are admitted to the hospital was to "remove the danger to self and others" and that there are similarities in goals and target dates for all acute patients. The staff member stated "We remove the dangerousness so patients can seek outpatient therapy. Treatment planning is not for me. It serves a purpose for external folks like yourself more than it does for the patient."

Based on policy review, medical record review and staff interview, the treatment team failed to delineate specific measurable short-term and long-term patient centered goals based on individual patient problems and failed to ensure short and long term goals had expected completion dates for 11 of 16 sample patients reviewed (#14, #15, #12, #1, #10, #5, #7, #8, #3, #2, #9). This failure hinders the ability of the team to measure change in the patient as a result of treatment interventions.

The findings included:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... Short-term objectives should also be reviewed and added to throughout the treatment course, if appropriate or indicated. Interventions should be completed and the name of the responsible person identified as well as the date of implementation of specific disciplines interventions.. ..."

1. Open medical record for Patient #14 revealed a 16 year-old female admitted on 11/18/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/18/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 11/19/2019 recorded "Pt (patient) will comply with meds. Pt will comply with therapy. Pt will report SI/SIB (suicide ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

2. Open medical record for Patient #15 revealed a 14 year-old female admitted on 11/13/2019 under petition for involuntary commitment with major depressive disorder and post traumatic stress disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/13/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 11/14/2019 recorded "Pt (patient) will comply with meds. Pt will comply with therapy. Pt will report SI/SIB (suicide ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1410 with Therapist #5 revealed short-term goals should include a target date.
Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

3. Open medical record for Patient #12 revealed a 15 year-old male admitted on 11/09/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/09/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 11/11/2019 recorded "DTS (danger to self) - Safety/CBT (cognitive behavioral therapy)" and "Depression - Zoloft (anti-depressive medication)." Review of the short-term goals revealed no target dates were documented for the short-term goals. Review of the nursing short-term goals documented on 11/18/2019 recorded "(name of patient) will notify staff of suicidal ideation." and "(name of patient) will learn 3 coping skills to use when stressed out." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1440 with Therapist #6 revealed short-term goals should include a target date.
Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.



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4. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" dated 08/01/2019 revealed the plan included one identified problem of "Danger to others". Review revealed no documented substantiated diagnosis. Review revealed no patient stated goals were identified or documented. Further review revealed no long term goal was identified or documented. Review revealed no therapy services interventions or short-term goals were documented for the identified problem. Further review revealed the responsible staff member "Name and Credentials" for "Therapy Services" were also blank on the Interdisciplinary Treatment Plan. Review revealed the patient was discharged on 11/09/2019 (100 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.

5. Open medical record for Patient #10 revealed a 16 year-old male admitted on 11/17/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/17/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 11/18/2019 recorded "Pt (patient) will comply with meds. Pt will comply with therapy." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.



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6. Closed medical record review for Patient #5 revealed a 16-year-old male admitted on 09/22/2019 at 1342 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/23/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/23/2019 recorded "DTS (danger to self) /Safety, CBT (cognitive behavioral; Mood- Zoloft/Neurontin." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

7. Closed medical record review for Patient #7 revealed a 13-year-old female admitted on 09/20/2019 at 0951 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/20/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/23/2019 recorded "Pt (Patient) will comply w/ (with) meds (medications). Pt. will comply w/ therapy. Pt will report SI /SIB (suicidal ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

8. Closed medical record review for Patient #8 revealed a 13-year-old female admitted on 09/20/2019 at 1054 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Aggression toward others" identified on the patient's problem list dated 09/20/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/23/2019 recorded "Pt (Patient) will comply w/ (with) meds (medications). Pt. will comply w/ therapy. Pt will report SI /SIB (suicidal ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.



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9. Closed medical record for Patient #3 revealed a 17 year-old female admitted on 09/10/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan Update" revealed "Self Harm" identified on the patient's problem list dated 09/10/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/11/2019 recorded "Pt (patient) will comply with meds. Pt will comply with therapy. Pt will report SI/SIB (suicide ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

10. Closed medical record for Patient #2 revealed a 13 year-old female admitted on 08/30/2019 under petition for involuntary commitment with major depressive disorder with suicide plan. Review of the "Interdisciplinary Treatment Plan Update" revealed "Suicide Ideation" identified on the patient's problem list dated 09/01/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Short-Term Goals must be measurable as evidenced by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/02/2019 recorded "Pt (patient) will comply with meds. Pt will comply with therapy. Pt will report SI/SIB (suicide ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.



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11. Closed medical record review on 11/19/2019 revealed Patient (Pt) #9 was a 17-year old female admitted on 09/13/2019 under petition for involuntary commitment with suicide ideation (thoughts of killing self). Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/13/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals/Interventions" that stated, "Short-Term Goals must be measurable as evidence by" and an area to document "Target Date." Review of the psychiatric provider's short-term goals documented on 09/16/2019 revealed "Pt will comply with meds. Pt will comply with therapy. Pt will report any SI/SIB (suicide ideations/self-injurious behaviors)." Review of the short-term goals revealed no target dates were documented for the short-term goals.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed short-term goals should include a target date. Interview revealed the target dates should have been documented. Interview confirmed the dates were blank.

Interview on 11/19/2019 at 1540 with the Director of Clinical Services revealed the purpose of the treatment team meeting was to discuss and finalize the patient's treatment plan. Interview revealed the plan is updated every seven days. Interview revealed short-term goals should include a target date. The staff member stated "Treatment plans are useless pieces of paper." Additional interview on 11/22/2019 at 1610 with the Director of Clinical Services revealed the treatment plan for acute patients that are admitted to the hospital was to "remove the danger to self and others" and that there are similarities in goals and target dates for all acute patients. The staff member stated "We remove the dangerousness so patients can seek outpatient therapy. Treatment planning is not for me. It serves a purpose for external folks like yourself more than it does for the patient."

Based on facility policy review, medical record review and staff interview, the facility failed to provide Master Treatment Plans (MTPs) for 13 of 16 sampled patients (#14, #15, #12, #1, #10, #6, #9, #5, #7, #8, #2, #3, #11) that included individualized and specific active treatment interventions based on each patient's presenting problems and treatment goals. Specifically, MTPs failed to include a focus of treatment based on each patient's unique presenting symptoms.

The findings included:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... Interventions should be completed and the name of the responsible person identified as well as the date of implementation of specific disciplines interventions.. ..."

1. Open medical record for Patient #14 revealed a 16 year-old female admitted on 11/18/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/18/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of nursing interventions dated 11/18/2019 revealed "Nursing staff will facilitate daily education groups to teach self-soothing skills, relaxation skills, and self-care skills." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the nursing group. Review revealed the goal was not specific or measurable. Review of the psychiatric provider interventions documented on 11/19/2019 recorded "Provider will educate. Provider will coordinate." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of therapy services interventions dated 11/19/2019 revealed "Therapy will facilitate daily psycho education sessions to assist patient in identifying triggers for depression/anxiety." Review of the therapy intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the therapy group. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

2. Open medical record for Patient #15 revealed a 14 year-old female admitted on 11/13/2019 under petition for involuntary commitment with major depressive disorder and post traumatic stress disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/13/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of nursing interventions dated 11/13/2019 revealed "Nursing staff will educate pt on the importance of following through with medication regimen and compliance." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement. Review revealed the goal was not specific or measurable. Review of the psychiatric provider interventions documented on 11/14/2019 recorded "Provider will educate. Provider will coordinate." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of therapy services interventions dated 11/14/2019 revealed "Therapist to facilitate daily psychotherapy group in order to provide psych education and to facilitate in building of coping skills." Review of the therapy intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the therapy group. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1410 with Therapist #5 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #5 reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

3. Open medical record for Patient #12 revealed a 15 year-old male admitted on 11/10/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/09/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of the psychiatric provider interventions documented on 11/11/2019 recorded "Q (every) 15 minutes" and "full compliance/efficacy." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of nursing interventions dated 11/18/2019 revealed "Nursing will monitor (name of patient) for safety" and "Nursing will educate (name of patient) on at least 3 coping skills to use when stressed out." Review of the nursing interventions revealed the frequency, amount and duration of each intervention was not included. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1440 with Therapist #6 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #6 reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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4. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" dated 08/01/2019 revealed the plan included one identified problem of "Danger to others". Review revealed no documented substantiated diagnosis. Review revealed no patient stated goals were identified or documented. Further review revealed no long term goal was identified or documented. Review revealed no therapy services interventions or short-term goals were documented for the identified problem. Further review revealed the responsible staff member "Name and Credentials" for "Therapy Services" were also blank on the Interdisciplinary Treatment Plan. Review revealed the patient was discharged on 11/09/2019 (100 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.

5. Open medical record for Patient #10 revealed a 16 year-old male admitted on 11/17/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 11/17/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of the psychiatric provider interventions documented on 11/18/2019 recorded "Q (every) 15 minutes" and "full compliance/efficacy." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of nursing interventions dated 11/19/2019 revealed "Nursing staff educate on prescribed medication." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the nursing group. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1410 with Therapist #5 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #5 reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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6. Review of a closed medical record on 11/19/2019 revealed Pt #6 was a 17 year-old female admitted on 09/20/2019 under petition for involuntary commitment with suicide ideation. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" and "Substance abuse" identified on the patient's problem list dated 09/20/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of nursing interventions dated 09/20/2019 revealed "Staff will encourage pt to name three positive goals for day, talk with staff if she feels she will harm self, give pt medication as prescribed and Pt will swallow meds when given by staff." Review failed to reveal the frequency, amount and duration of the patient's involvement. Review of the therapy service interventions on 09/21/2019 revealed "Therapist to facilitate daily psychoeducation therapy group in order to provide psychoeducation and facilitate building of coping skills" and "Therapist to facilitate family therapy session in order to discuss presenting concerns, treatment history and initial discharge plans." Review of the therapy intervention revealed it failed to document the amount and duration for the patient's involvement in the therapy group. Review of the therapy intervention revealed it failed to document the amount, frequency and duration of the family therapy session. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

7. Review of a closed medical record on 11/19/2019 revealed Pt #9 was a 17 year-old female admitted on 09/13/2019 under petition for involuntary commitment with suicide ideation. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/13/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Intervention" that stated "Interventions (include frequency, amount and duration)." Review revealed the section was blank and did not include documentation of goals or interventions. Review of the nursing interventions dated 09/13/2019 revealed "Staff will educate pt on healthy coping skills and how to best incorporate them daily and monitor patient to ensure safe behaviors." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the nursing group. Review revealed the goal was not specific or measurable. Review of the psychiatric provider interventions dated 09/16/2019 revealed the provider will educate on meds, coordinate with all staff and educate on disease process. Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of the therapy services intervention dated 09/15/2019 revealed "Therapist to facilitate family therapy session in order to discuss presenting concerns, treatment history and initial discharge plans" and "Therapist to provide daily psychotherapy group in order to provide psychoeducation and to facilitate building of coping skills." Review of the therapy intervention revealed it failed to document the amount, frequency and duration of the group or family therapy sessions. Review revealed the goal were not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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8. Closed medical record review for Patient #5 revealed a 16-year-old male admitted on 09/22/2019 at 1342 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/23/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Interventions (include frequency, amount and duration)." Review of the psychiatric provider interventions documented on 09/23/2019 recorded "DTS (danger to self) - Q (every) 15 minutes/CBT (cognitive behavioral therapy)" and "Mood-full compliance c (with) meds/safety." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed there was no nursing short-term goals and no nursing interventions documented on the "Interdisciplinary Treatment Plan."

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

9. Closed medical record review for Patient #7 revealed a 13-year-old female admitted on 09/20/2019 at 0951 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self" identified on the patient's problem list dated 09/20/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Interventions (include frequency, amount and duration)." Review of the psychiatric provider interventions documented on 09/23/2019 recorded "Provider will educate on meds (medications). Provider will coordinate. Provider will educate on disease." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review of nursing interventions dated 09/20/2019 revealed "Staff will make sure safety checks are performed as ordered." and "Staff will adm (administer) any ordered medications. Staff will make sure pt (patient) attends group." Review of the nursing interventions revealed the frequency, amount and duration of each intervention was not included. Review revealed the goal was not specific or measurable. Review of the therapy services interventions dated 09/21/2019 revealed "Therapist to facilitate daily psychotherapy group in order to provide psychoeducation and to facilitate building of coping skills" and "Therapist to facilitate family therapy session in order to discuss presenting concerns treatment history and initial discharge plans." Review of the therapy interventions revealed the frequency, amount and duration of each intervention was not included. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

10. Closed medical record review for Patient #8 revealed a 13-year-old female admitted on 09/20/2019 at 1054 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" revealed "Aggression toward others" identified on the patient's problem list dated 09/20/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short-Term Goals and Interventions" that stated, "Interventions (include frequency, amount and duration)." Review of the psychiatric provider interventions documented on 09/23/2019 recorded "Provider will educate on meds (medications). Provider will coordinate. Provider will educate on disease." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review of nursing interventions dated 09/20/2019 revealed "Patient will attend groups and self evaluate progress through staff, nurse, and therapist" and "Patient will be educated by Infection control nurse and unit nurse on safe sex practice." Review of the nursing interventions revealed the frequency, amount and duration of each intervention was not included. Review revealed the goal was not measurable. Review of the therapy services interventions dated 09/20/2019 revealed "Therapist to facilitate daily psychotherapy group in order to provide psychoeducation and to facilitate building of coping skills" and "Therapist to facilitate family therapy session in order to discuss presenting concerns treatment history and initial discharge plans." Review of the therapy interventions revealed the frequency, amount and duration of each intervention was not included. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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11. Closed medical record for Patient #2 revealed a 13 year-old female admitted on 08/30/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Danger to self and others" identified on the patient's problem list dated 08/31/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of nursing interventions dated 09/07/2019 revealed "Staff will encourage (patient) to attend all groups/activities so she can learn new and appropriate coping skills. Nursing staff will encourage and administer medication to (patient) as ordered by MD." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement. Review revealed the goal was not specific or measurable. Review of the psychiatric provider interventions documented on 09/02/2019 recorded "Provider will educate on meds. Provider will coordinate with all staff. Provider will educate on disease process." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of therapy services interventions dated 09/01/2019 revealed "Therapist to facilitate daily psychotherapy group in order to provide psych education and to facilitate in building of coping skills. Therapist to facilitate family therapy session in order to discuss presenting concerns, treatment history, and initial discharge plans." Review of the therapy intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the therapy group. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.

12. Closed medical record for Patient #3 revealed a 17 year-old female admitted on 09/10/2019 under petition for involuntary commitment with major depressive disorder. Review of the "Interdisciplinary Treatment Plan" revealed "Self Harm" identified on the patient's problem list dated 09/10/2019. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions" that stated "Interventions (include frequency, amount and duration)." Review of nursing interventions dated 09/10/2019 revealed "Nursing staff will provide daily med education at med pass." Review of the nursing intervention revealed it failed to document the frequency, amount and duration for the patient's involvement. Review revealed the goal was not specific or measurable. Review of the psychiatric provider interventions documented on 09/11/2019 recorded "Provider will educate on meds. Provider will coordinate with all staff. Provider will educate on disease process." Review of the provider interventions revealed it failed to document the frequency, amount and duration for the modality. Review revealed the goal was not specific or measurable. Review of therapy services interventions dated 09/11/2019 revealed "Therapist to facilitate daily psycho-education groups to assist pt in stabilizing behavior. Therapy sessions will facilitate a family session to assit patient in accomplishing a safety and discharge plan. Therapy services will coordinate with patient the tx (Treatment) plan to establish an aftercare plan prior to discharge." Review of the therapy intervention revealed it failed to document the frequency, amount and duration for the patient's involvement in the therapy group. Review revealed the goal was not specific or measurable.

Interview on 11/22/2019 at 1515 with Therapist #4 revealed treatment modalities should include the amount, frequency and duration of the intervention for all disciplines. Interview revealed the amount, frequency and duration for the interventions were missing and should be there. Therapist #4 stated the modality is "lacking patient participation. It is not patient specific." The staff member reviewed the MTP and confirmed the treatment modalities were not individualized, specific or measurable.



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13. Review of an open medical record revealed Patient #11 was a twenty year old female admitted to the facility under involuntary commitment (IVC) determination on 10/22/2019 at 2020 for agitation, and aggression toward staff and peers at a group home where she resided. Review of the "Interdisciplinary Treatment Plan" dated 10/22/2019 revealed "Danger to self" was identified on the patient's problem list. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions." Review revealed short term goals and interventions had been entered by nursing staff, recreational therapy staff, and therapy services staff on 10/22/2019, 10/23/2019, and 10/24/2019 respectively. Review of nursing goals and interventions dated 10/22/2019 revealed "Staff will educate pt (patient) on healthy coping skills and their utilization daily." Review of the nursing intervention revealed it failed to document the amount and duration for the patient's involvement in the nursing group. Review revealed the intervention was not specific or measurable. Review revealed the psychiatric provider section for the initial treatment plan on 10/22/2019 was blank, and on 11/07/2019, the "Interdisciplinary Treatment Plan Update" lacked documented input by nursing staff.

Interview on 11/19/2019 at 1125 with Therapist #11 revealed the initial treatment plan was expected to be developed within twenty-four hours of a patient's arrival. Interview revealed treatment modalities included documentation of the amount, frequency and duration of the intervention for by the involved disciplines.

Interview on 11/19/2019 at 1540 with the Director of Clinical Services revealed the purpose of the treatment team meeting was to discuss and finalize the patient's treatment plan. Interview revealed the plan is updated every seven days. Interview revealed treatment modalities should be specific and measurable. Interview revealed the modalities should be defined by amount, frequency and duration for each modality. Additional interview on 11/22/2019 at 1610 with the Director of Clinical Services revealed the treatment plan for acute patients who are admitted to the hospital was to "remove the danger to self and others" which results in similarities in goals and target dates for all acute patients. The staff member stated "We remove the dangerousness so patients can seek outpatient therapy. Treatment planning is not for me. It serves a purpose for external folks like yourself more than it does for the patient."

Based on policy review, medical record review and staff interview, the facility staff failed to include responsibilities of each member of the treatment team for 3 of 16 sampled patients (#1, #11, #5).

The findings include:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... Short-term objectives should also be reviewed and added to throughout the treatment course, if appropriate or indicated. Interventions should be completed and the name of the responsible person identified as well as the date of implementation of specific disciplines interventions.. ..."

1. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" dated 08/01/2019 revealed the plan included one identified problem of "Danger to others". Review revealed no therapy services interventions or short-term goals were documented for the identified problem. Further review revealed the responsible staff member "Name and Credentials" for "Therapy Services" were also blank on the Interdisciplinary Treatment Plan. Review revealed the patient was discharged on 11/09/2019 (100 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed interventions and goals should have been documented. Interview revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.






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2. Review of an open medical record revealed Patient #11 was a twenty year old female admitted to the facility under involuntary commitment (IVC) determination on 10/22/2019 at 2020 for agitation, and aggression toward staff and peers at a group home where she resided. Review of the "Interdisciplinary Treatment Plan" dated 10/22/2019 revealed "Danger to self" was identified on the patient's problem list. Review of the "Interdisciplinary Treatment Plan" form revealed a section to document "Short- Term Goals and Interventions." Review revealed short term goals and interventions had been entered by nursing staff, recreational therapy staff, and therapy services staff on 10/22/2019, 10/23/2019, and 10/24/2019 respectively. Review revealed the psychiatric provider section for the initial treatment plan on 10/22/2019 was blank, and on 11/07/2019 an "Interdisciplinary Treatment Plan Update" lacked documented updated input from nursing.

Interview on 11/19/2019 at 1125 with Therapist #11 revealed the initial treatment plan was expected to be developed within twenty-four hours of a patient's arrival. Interview revealed the treatment plan modalities should include all members of the treatment team. Interview revealed treatment modalities failed to include the psychiatric provider and nursing interventions.



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3. Closed medical record review on 11/19/2019 for Patient #5 revealed a 16-year-old male admitted on 09/22/2019 at 1342 under petition for involuntary commitment with suicidal ideations. Review of the "Interdisciplinary Treatment Plan" dated 09/23/2019 revealed the plan included one identified problem of "Danger to self". Review revealed no Nursing interventions or short-term goals were documented for the identified problem. Further review revealed the responsible staff member "Name and Credentials" for "Nursing" were also blank on the Interdisciplinary Treatment Plan. Review revealed the patient was discharged on 09/27/2019 (5 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed interventions and goals should have been documented. Interview revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview confirmed the treatment plan failed to include the responsibilities of each member of the treatment team and was incomplete.

Interview on 11/19/2019 at 1540 with the Director of Clinical Services revealed the purpose of the treatment team meeting was to discuss and finalize the patient's treatment plan. Interview revealed the plan is updated every seven days. Interview revealed short-term goals should include a target date. The staff member stated "Treatment plans are useless pieces of paper." Additional interview on 11/22/2019 at 1610 with the Director of Clinical Services revealed the treatment plan for acute patients that are admitted to the hospital was to "remove the danger to self and others" and that there are similarities in goals and target dates for all acute patients. The staff member stated "We remove the dangerousness so patients can seek outpatient therapy. Treatment planning is not for me. It serves a purpose for external folks like yourself more than it does for the patient."

Based on the facility's policy, medical record review and staff interview, the facility staff failed to ensure documentation of an evaluation of a patient's individualized treatment plan progress toward goals for 5 of 16 sampled patients (#1, #12, #13, #8, #3).

The findings include:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... In order to determine the effectiveness of the interdisciplinary person centered treatment plan, weekly reviews are done by the interdisciplinary team. This review will provide valuable information about the patient progress, need for continued treatment, and revision of interventions as well as discharge planning. The major areas addressed will be: 1. Reason for continued hospitalization. 2. Progress on identified goals and objectives. ... The patient's progress, as well as revision to the treatment plan based on these summaries, are reflected in the treatment plan update. ..."

1. Closed medical record review on 11/19/2019 for Patient #1 revealed a 16 year-old male admitted on 08/01/2019 under petition for involuntary commitment with mood disorder. Review of the "Interdisciplinary Treatment Plan" dated 08/01/2019 revealed the plan included one identified problem of "Danger to others". Review revealed no documented diagnosis, patient strengths or weaknesses. Review revealed no therapy services interventions or short-term goals were documented for the identified problem. Further review revealed the responsible staff member "Name and Credentials" for "Therapy Services" were also blank on the Interdisciplinary Treatment Plan. Review revealed treatment plan updates were completed without documented therapy services interventions, short-term goals or a long term goal on 08/16/2019 (15 days after admission); 08/21/2019, 08/30/2019, 09/06/2019, 09/13/2019, 09/27/2019 (14 days after last review); 10/11/2019 (14 days after last review); 10/18/2019, 10/25/2019 and 11/08/2019 (14 days after last review). Review revealed the patient was discharged on 11/09/2019 (100 admission days).

Interview on 11/22/2019 at 1440 with Therapist #6 revealed interventions and goals should have been documented. Interview revealed the treatment plan should have been reviewed and if it was noted to be incomplete it should have been completed. Interview revealed treatment plans are supposed to be reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview confirmed the treatment plan was incomplete for Patient #1.



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2. Review on 11/19/2019 of an open medical record for Patient #12 revealed a 15 year-old male admitted on 11/09/2019 with major depressive disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 11/09/2019 revealed the plan included one identified problem with long-term and short-term goals recorded. Review of Problem #1 revealed a long-term goal documented on 11/10/2019 of "(Patient name's) danger to self will stabilize prior to discharge as evidenced by agreement to safety plan, no attempts to harm self, taking meds as directed." Review of the record revealed a treatment plan review was conducted on 11/09/2019 (day of admission). Review of the progress toward Problem #1 dated 11/18/2019 (9 days after initial treatment plan review) revealed the problem was resolved. Review of nursing progress note revealed "No scheduled meds. Mother denied all med. ..." Review of therapy services progress note revealed "(patient name) has been disruptive throughout group. (patient name) has made progress toward his treatment goals." Review of the psychiatrist progress note recorded the patient was responding to therapy. Review of the notes failed to describe the patient's progress toward his identified goal of agreement to a safety plan and taking medications as directed. Review of the Interdisciplinary Treatment Plan revealed the goal was resolved and no new goals or revisions were made to the treatment plan.

Interview on 11/19/2019 at 1415 with Therapist #6 revealed she was the patient's primary therapist. Interview revealed the patient was admitted with suicide ideations and substance abuse. Interview revealed a long term goal was identified on 11/10/2019 that included taking medications as directed to stabilize the patient and maintain safety. Interview revealed the patient's mother would not agree to administration of any medications. Interview revealed that the patient was frustrated with not getting medications. Therapist #6 reviewed the progress notes documented on the treatment plan and stated she was unable to associate the patient's behaviors toward the stated goal. Interview reveled the treatment plan update should have been completed seven days after the initial treatment plan meeting on 11/09/2019 and it was completed late. The therapist reported the patient was scheduled for discharge on 11/19/2019. Interview revealed there was a family session scheduled on 11/19/2019 at 1500 to discuss the patient's discharge.

Interview on 11/20/2019 at 1500 with Therapist #6 revealed Patient #12 had not been discharged. After the family meeting on 11/19/2019 the patient's mother consented to medication and the discharge was delayed. Interview revealed no new treatment goals were added to the patient's treatment plan after the identified goal had been resolved on 11/18/2019.



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3. Review of an open medical record revealed Patient #13 was an eighty four year old female admitted to the facility under involuntary commitment (IVC) determination on 11/08/2019 at 2020 for suicidal ideation at an assisted living facility where she resided. Review of the "Interdisciplinary Treatment Plan" dated 11/08/2019 revealed Problem #1 was listed as "Danger to self" and Problem #2 "Dementia." was identified on the patient's problem list. Review of the "Interdisciplinary Treatment Plan" form revealed the identified "Short- Term Goals and Interventions" were expected to be achieved between 11/16/2019 and 11/23/2019. Review of the medical record revealed no updated documentation of Patient #13's Treatment Plan and progress toward goals and interventions between initiation and 11/21/2019 (14 days).

Interview on 11/19/2019 at 1125 with Therapist #11 revealed an initial treatment plan was expected to be developed within twenty-four hours of a patient's arrival. Interview revealed treatment modalities included documentation of the amount, frequency and duration of the intervention by the involved disciplines and updated by staff on a weekly basis.

Interview on 11/22/2019 at 1612 with the Director of Clinical Services revealed the purpose of treatment team was to discuss a patient's treatment plan and progress toward goals. Interview revealed the plan is updated every seven days and "I do not quibble with the idea that our plans can be improved." The Director of Clinical services stated, "People need to be able to articulate what they are doing and document it."



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4. Review on 11/19/2019 of a closed medical record for Patient #8 revealed a 13-year-old female admitted on 09/20/2019 under petition for involuntary commitment with suicidal ideation. Review of the "Interdisciplinary Treatment Plan" dated 09/21/2019 revealed the plan included one identified problem of :Aggression toward others". Review of the medical record revealed a "Treatment Plan Update" was conducted on 09/23/2019 and on 09/30/2019 (7 days after last review). Review of the progress toward Problem #1 dated 09/30/2019 revealed the problem had "Minimal Progress". Review revealed there was no documentation from Nursing on the update. Review revealed no new goals or revisions were made to the treatment plan.

Interview on 11/19/2019 at 1415 with Therapist #6 revealed revisions to the treatment plan should be made when the modalities are not effective and the patient is making minimal progress. Interview revealed no revisions were made to the patient's treatment plan when reviewed.



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5. Review on 11/19/2019 of a closed medical record for Patient #3 revealed a 17 year-old female admitted on 09/10/2019 with major depressive disorder. Review of the "Interdisciplinary Master Treatment Plan" dated 09/10/2019 revealed the plan included one identified problem with long-term and short-term goals recorded. Review of Problem #1 revealed a long-term goal documented on 09/10/2019 of "(Patient name's) potential for self-harm will stabilize x 3 days prior to discharge as evidenced by absence of suicidal ideation, development of a safety plan and improved communications skills regarding her emotions." Review of the record revealed a treatment plan review was conducted on 09/11/2019 (one day after admission). Review of the progress toward Problem #1 dated 09/11/2019 (1 days after initial treatment plan review) "New admission--has not had opportunity to attend group sessions yet." Review of the psychiatrist progress note recorded the patient was responding to therapy. Review of the notes failed to describe the patient's progress toward his identified goal of agreement to a safety plan and taking medications as directed. Review of the Interdisciplinary Treatment Plan revealed the goal was resolved and no new goals or revisions were made to the treatment plan.

Interview on 11/22/2019 at 1440 with Therapist #6 revealed interventions and goals should have been documented. Interview revealed treatment plans are supposed to be reviewed and updated every 7 days and the plan should have been updated and completed with each review. Interview revealed the staff member was unable to determine why the goal was resolved and no new goals or revisions made to the treatment plan.

NC00156256, NC00156473