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I. Based on record review and interview, the facility failed to provide social work assessments for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11 and L12) that included conclusions and recommendations describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of input to the interdisciplinary team for treatment planning. (Refer to B108)

II. Based on record review, interviews and policy review, the facility failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11, and L12) included physician interventions that were individualized based on the patient needs. In addition, 3 of 8 active sample patients (A10, A15, and L10) did not include individualized social work interventions, and 2 of 8 active sample patients (A10 and A15) did not include individualized nursing interventions. Instead, the interventions were listed as generic monitoring and assessing functions. This failure results in a treatment plan that does not reflect a comprehensive, integrated and individualized approach to multidisciplinary treatment. (Refer to B122)

III. Based on document review, interviews and record review, the facility failed to ensure that all patients in the acute phase of psychiatric illness received acute psychiatric care. Five of 8 active sample patients (A15, A18, A19, L10 and L11) were designated as residential treatment patients but were housed on acute care units at the time of survey. These patients received a less intense level of care than patients designated as "acute care." They received less individual and family therapy sessions per week than acute care patients. They also received fewer psychiatrist visits per week compared to acute care patients. This failure places patients at risk for less than adequate treatment. (Refer to B125-I)

IV. Based on observation, record review and interviews, the facility failed to provide dignity and privacy for 5 of 8 active sample patients (A10, A15, A18, A19, and L8) and 13 additional non- sample patients (A1, A2, A6, A7, A8, A9, A12, A13, A14 A16, A20, L6 and L14) by having these patients sleep on the floor in the hall overnight on a regular basis. The patients were fully exposed to light/noise and experienced no privacy during their sleeping hours. This failure can contribute to vulnerability and anxiety and is not conducive to feelings of safety and self-esteem. (Refer to B125-II)

VI. Based on record review, interview and policy review, the facility failed to ensure that social workers wrote progress notes for 7 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11) that contained information about discharge planning. This failure impedes the treatment team's ability to assess or evaluate the patient's response to treatment and readiness for discharge. (Refer to B128)

VII. Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 5 of 5 discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). Additionally, the physician dictation for 3 of 5 patient records (D1, D3 and D4) was completed after the scheduled outpatient appointment follow up date. These failures result in a lack of critical clinical information indicating the patient's level of psychiatric symptomatology and risk being available to aftercare providers. (Refer to B134)

Based on record review and interviews, the facility failed to admit psychiatric patients into acute psychiatric beds. Instead, patients in the acute phase of psychiatric illness were directly admitted into residential treatment status on a frequent basis. The facility employs two psychiatrists for a total of 60 hours per week of direct care (including night call and weekends). Interviews revealed that the psychiatrists would be unable to care for 50 acute psychiatric patients at the acute level of care with their current medical contingent if all patients were admitted to the facility as an acute psychiatric patient rather than a residential care patient.

The facility had 50 CMS certified acute psychiatric patient beds divided into two units: a 20 bed Latency Unit (ages 4-12), and a 30 bed Adolescent Unit (ages 12-17). The administrators of the facility have been interchangeably utilizing these beds for either acute psychiatric care or residential care.

At the beginning of the survey, 8/13/12, there was a census of 34 patients, 30 of whom were on residential treatment status (17 of 20 patients on the adolescent unit and 13 of 14 patients on the latency unit) including 6 of 8 active sample patients (A15, A18, A19, L8, L10 and L11).

The failure to admit patients into acute psychiatric beds places patients at risk to receive a lower, less intense level of care than may be required for the admitting diagnosis or problems.

Findings include:

A. Record review

1. Review of facility report titled "Comparative Report of Professional Services," dated July 2012, noted the following information:

For the month of July 2012:

There were a total of 27 patients admitted (11 were admitted as acute patients and 16 were admitted directly to residential treatment).
The average daily census was 0.32 for the Latency Unit Acute beds and 12.77 for the Latency unit Residential Treatment beds.
The average daily census was 1.45 for the Adolescent Unit Acute Beds and was 19.97 for the Adolescent Unit Residential Treatment beds.

For the year to date:

There were a total of 272 admissions to the facility (109 on acute status and 163 on residential treatment status).
The average daily census was 0.42 for the Latency Unit Acute beds and 16.98 for Latency unit Residential Treatment beds.
The average daily census was 2.15 for the Adolescent Unit Acute Beds and was 22.61 for the Adolescent Unit Residential Treatment beds.

B. Interviews

1. In an interview on 8/13/12 at 8:45 AM, the Assistant Administrator of Operations was shown the patient census. She informed the surveyors that patients in the facility were directly admitted to residential status. She confirmed that the facility had fifty psychiatric beds, all certified by CMS as acute psychiatric beds. She stated that the State of Oklahoma Health Authority allowed the facility to use the beds as "swing beds" and have patients there as either acute patients or residential patients.

2. In an interview on 8/14/12 at 1 PM, the Clinical Director confirmed the findings and reported that "patients on residential status do receive less individual care than acute patients," namely "One physician visit a week instead of three, and two individual/family sessions a week instead of three." She also stated, "My clinicians would be hard pressed to see all of those kids each week, and I don't think we have enough medical coverage for 50 acute patients."

3. In an interview on 8/14/12 at 2:15 PM, when asked about the admission process, the Medical Director stated that the physicians decide what program the patients are admitted to and that it depends on acuity. For example, "if the patient is in an ER at 4 in the morning, then s/he is acute; otherwise, we admit to residential." When the Medical Director was asked about having 50 acute psychiatric patients in the facility and whether the 1.5 FTE psychiatrists currently on staff could provide care for all of those patients, he stated, "We can't do that at all. We can't see all of those kids three times a week." The Medical Director also noted that patients remain on acute status for only 5 days after admission and are then transitioned to residential status because "that's all the Oklahoma Health Authority will pay for."

Based on record review and interview, the facility failed to provide social work assessments for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11 and L12) that included conclusions and recommendations describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of input to the interdisciplinary team for treatment planning.

Findings include:

A. Record Review

The Psychosocial Evaluations (completion dates in parentheses) for the following active sample patients did not include any information about anticipated social work roles or discharge planning information: A10 (8/8/12); A15 (7/30/12); A18 (4/28/12); A19 (4/4/12); L8 (8/10/12); L10 (11/18/11); L11 (7/24/12) and L12 (8/9/12).

B. Interview

In an interview on 8/14/12 at 1 PM, the Clinical Director agreed with the above findings and stated, "Our 20 page Integrated Biopsychosocial Assessment form doesn't have a section for that information."

Based on record review, interviews and policy review, the facility failed to ensure that the Master Treatment Plans of 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11, and L12) included physician interventions that were individualized based on patient needs. In addition, 3 of 8 active sample patients (A10, A15, and L10) did not include individualized social work interventions, and 2 of 8 active sample patients (A10 and A15) did not include individualized nursing interventions. Instead, the interventions were listed as generic monitoring and assessing functions. This failure results in a treatment plan that does not reflect a comprehensive, integrated and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. For sample patient A10, the Master Treatment Plan dated 8/8/12, had the following interventions for the identified problem "Suicidal Ideation":
MD: "Maintain suicide, self-harm precautions."
Social Work: "Individual and family therapy sessions to address dysfunctional communication patterns and teach assertiveness communication utilizing 'I' statements."
Nursing: "Meet 1:1 with patient 3-5 minutes to explore triggers to suicidal thoughts/threat and teach coping skills."

2. For sample patient A15, the Master Treatment Plan dated 7/30/12, had the following interventions for the identified problem "Harm to self ":
MD: "Maintain suicide and self-harm precautions. Continue Zoloft."
Social Work: "Individual and family sessions to identify triggers and solutions to the problem."
Nursing: "Meet 1:1 with patient 3-5 minutes to explore triggers to suicidal thoughts and teach coping skills."

3. For sample patient A18, the Master Treatment Plan dated 8/13/12, had no physician interventions for the identified problems "Mood Disturbance", "Family Conflict/Defiance," and "Defiance."

4. For sample patient A19, the Master Treatment Plan dated 7/19/12 had the following physician interventions:
For the identified problem "Mood Disturbance":
MD: "Treatment plan update. Med Review."
For the identified problem, "Impulsivity/Defiance":
MD: "Med Review."
For the identified problem, "Family Conflict":
MD: "Med Review."

5. For sample patient L8, the Master Treatment Plan dated 8/10/12 had the following physician interventions:
For the identified problem "Mood Instability/Anger":
MD: "Meet with patient weekly to evaluate progress in individual/group therapy."
For the identified problem, "ADHD Symptoms" (Attention Deficit Hyperactivity Disorder):
MD: "Monitor hyperactivity/impulsivity in groups or school."
For the identified problem, "Family Conflict":
MD: "Meet weekly with patient to evaluate progress in family sessions."
For the identified problem, "Poor Social Skills":
MD: "Monitor progress in group and school."

6. For sample patient L10, the Master Treatment Plan dated 7/19/12 had the following interventions:
For the identified problem "Defiance":
MD: "Continue Concerta, Ritalin and Clonidine for hyperactivity/impulsivity. Adjust as needed."
Social Work: "Individual and family sessions to provide support and encouragement."
For the identified problem, "Impulsivity":
MD: "Continue Concerta, Ritalin, and Clonidine for hyperactivity/impulsivity. Adjust as needed."
For the identified problem, "Symptoms of abuse":
MD: "Meet with patient weekly to evaluate progress in individual/family therapy."
For the identified problem, "Reactive attachment disorder":
MD: "Meet with patient weekly to evaluate progress in individual and family therapy."
Social Work: "Individual and family sessions to provide support, validation, and encouragement. For the identified problem, "Difficulty making and keeping friends. Aggressive daily."
MD: "Continue Seroquel for agitation. Adjust as needed."

7. For sample patient L11, the Master Treatment Plan dated 7/31/12 had the following physician interventions:
For the identified problem, "Mood Disturbance":
MD: "Continue Prozac for depressive symptoms."
For the identified problem, "Social Skills":
MD: "Continue Prozac for depressive symptoms. Adjust as needed."
For the identified problem, "Family Conflict":
MD: "Meet with patient weekly to evaluate progress in individual and family therapy."

8. For sample patient L12, the Master Treatment Plan dated 8/9/12 had no physician interventions for the single identified problem "Risk of Harm to Self."

B. Interview

1. In an interview on 8/14/12 at 12:50 PM, the Clinical Director (Administrator responsible for Social Work) stated, "I see what you mean. The interventions are not specific."

2. In an interview on 8/14/12 at 2 PM, the Medical Director stated, "I can see that they are not individualized but I don't know how I can do that, especially for the new admits."

3. In an interview on 8/15/12 at 8:25 AM, the Director of Nursing stated, "I see that interventions are not individualized."

C. Policy Review

In a facility policy titled, "Treatment Planning" numbered CS-013 and dated 03/02/10 states, "It is the policy of Willow Crest Hospital/Moccasin Bend Ranch to provide responsive, individualized, interdisciplinary treatment planning for patients." In addition it states, "Interventions will be noted with a brief statement on the form next to the appropriate discipline, and should be a measurable, behavior specific, and time-limited statement of what the patient is expected to accomplish during the course of hospitalization."

I. Based on document review, interviews and record review, the facility failed to ensure that all patients in the acute phase of psychiatric illness received acute psychiatric care. Five of 8 active sample patients (A15, A18, A19, L10 and L11) were designated as residential treatment patients housed on acute care units at the time of survey. These patients received a less intense level of care by receiving less individual and family therapy sessions per week than acute care patients. These patients also received less psychiatrist visits per week compared to acute care patients. This failure places patients at risk for less than adequate treatment.

Findings include:

A. Document Review

1. The facility patient census report dated 8/13/12 showed a total census of 34 patients, 30 of whom were on residential treatment status, including 6 of 8 active sample patients (A15, A18, A19, L8, L10 and L11).

2. The facility policy titled "Clinical responsibilities" specified that patients on acute care status are to receive psychiatric visits three times a week, individual therapy sessions twice a week and family sessions once a week. Patients in the residential treatment program are to receive one psychiatric visit a week, one individual therapy visit, and one family visit per week. Progress notes are to be written for each visit/patient contact.

B. Interviews

1. In an interview on 8/14/12 at 1 PM, the Clinical Director (administrator responsible for counseling services) reported that "patients on residential status receive less individual care than do acute patients." He stated that these patients receive "One physician visit a week instead of three, and two individual/family sessions a week instead of three."

2. In an interview on 8/14/12 at 2 PM, the Medical Director stated, that based on his observations of patient care at the facility, residential patients receive less physician visits per week than acute patients, even though, clinically, there may be no difference in patient acuity between acute and residential patients except for payment status. The Medical Director also stated, "We only do family therapy weekly when kids are on residential status because the state requires it." He confirmed the findings that when patients are admitted or transferred to residential status, they receive less intensive care while being housed on an acute care unit.

C. Record Review (dates of progress notes in brackets)

1. Patient A15, admitted to acute status on 7/28/12 and transferred to residential status on 8/2/12, had the following visits:

Psychiatrist: Acute [7/29/12, 7/30/12, 7/31/12], Residential [8/2/12]
Individual Therapy: Acute [7/30/12, 7/31/12], Residential [8/6/12]
Family Therapy: Acute [7/31/12], Residential [8/7/12, 8/14/12]

2. Patient A18, admitted to residential status on 5/1/12, had the following visits:

Psychiatrist: Residential [5/8/12, 5/15/12, 5/22/12, 5/29/12, 6/5/12, 6/12/12, 6/15/12, 6/19/12, 6/24/12, 6/26/12, 7/3/12, 7/10/12, 7/17/12, 7/24/12, 7/31/12, 8/7/12]
Individual Therapy: Residential [6/5/12, 6/12/12, 6/19/12, 6/26/12, 7/3/12, 7/12/12, 7/16/12, 7/23/12, 7/30/12, 8/6/12, 8/11/12]
Family Therapy: Residential [6/15/12, 6/23/12, 6/29/12, 7/7/12, 7/11/12, 7/21/12, 7/28/12]

3. Patient A19, admitted to residential status on 4/7/12, had the following visits:

Psychiatrist: Residential [6/7/12, 6/14/12, 6/21/12, 6/28/12, 7/12/12, 7/19/12, 7/26/12, 8/9/12]
Individual Therapy: Residential [6/12/12, 6/21/12, 6/28/12, 7/6/12, 7/11/12, 7/19/12, 7/25/12, 8/1/12, 8/10/12]
Family Therapy: Residential [6/15/12, 6/22/12, 6/29/12, 7/5/12, 7/9/12, 7/18/12, 7/25/12, 8/1/12, 8/10/12]

4. Patient L10, admitted to residential status on 11/17/11, had the following visits:

Psychiatrist: Residential [4/25/12, 5/2/12, 5/9/12, 5/16/12, 5/23/12, 5/30/12, 6/7/12, 6/13/12, 6/20/12, 6/27/12, 7/3/12, 7/11/12, 7/18/12, 7/25/12, 8/1/12, 8/8/12]
Individual Therapy: Residential [6/5/12, 6/14/12, 6/18/12, 6/28/12, 7/6/12, 7/9/12, 7/19/12, 7/23/12, 8/2/12, 8/8/12]
Family Therapy: Residential [6/1/12, 6/6/12, 6/11/12, 6/20/12, 6/29/12, 7/2/12, 7/11/12, 7/16/12, 7/24/12, 7/30/12, 8/13/12]

5. Patient L11, admitted to acute status on 7/24/12 and transferred to residential status on 7/28/12, had the following visits:

Psychiatrist: Acute [7/26/12], Residential [8/1/12, 8/8/12]
Individual Therapy: Acute [7/24/12, 7/26/12], Residential [7/30/12, 8/2/12, 8/6/12, 8/13/12]
Family Therapy: Acute [7/25/12], Residential [8/9/12]



II. Based on observation, record review and interviews, the facility failed to provide dignity and privacy for 5 of 8 active sample patients (A10, A15, A18, A19, and L8) and 13 additional non- sample patients (A1, A2, A6, A7, A8, A9, A12, A13, A14 A16, A20, L6 and L14) by requiring these patients to sleep on the floor in the hallway overnight on a regular basis. This failure results in patients being fully exposed to light/noise and experiencing no privacy during their sleeping hours, which can contribute to vulnerability and anxiety and is not conducive to feelings of safety and self-esteem.

Findings include:

A. Observation

During an observation on 8/14/12 from 6 AM to 6:45 AM, the physician surveyor and nurse surveyor observed 15 adolescents and 3 latency patients sleeping in the hallway with the overhead lights on. Fourteen of the adolescents were sleeping on the floor, and one adolescent (A19) was sleeping on a blanket. The three latency patients were sleeping on cots. (Five of these patients were active sample patients (A10, A15, A18, A19, and L8), and 13 were non-sample patients (A1, A2, A6, A7, A8, A9, A12, A13, A14 A16, A20, L6 and L14).

B. Record review

1. Patient A19's physician's progress note (written by the Medical Director) dated 7/5/12 (with no time noted), listed as the "Chief Complaint: (patient's own words) I want to sleep in my room." The physician did not address this issue in the progress note. There was no mention of what the staff would do to address the patient's complaint.

2. Patient A19's physician progress note (written by the Medical Director) dated 8/2/12 (with no time noted) listed as the "Chief Complaint: (patient's own words) Can I sleep in my room?" The physician did not address this issue in the progress note. There was no mention of what the staff would do to address the patient's question.

C. Interviews

1. In an interview on 8/14/12 at 6:05 AM, RN4 stated, "Any kids on precautions sleep in the hall. It is much easier to monitor them when they are in the hall."

2. In an interview on 8/14/12 at 6:15 AM, MHT2 was asked about Patient A19 who was observed sleeping on the floor, wrapped in blankets and without a mattress. MHT2 reported that Patient A19 refuses to bring out his/her mattress into the hallway because "[A19] wants to sleep in [his/her] bedroom and is resisting following our rules."

3. On 8/14/12 at 2:15 PM, the Medical Director stated, "I had no idea the kids were sleeping in the hall." When he was shown the two progress notes that he had written about Patient A19, he stated, "I guess I didn't address [A19's] chief complaint."

Based on record review, interview and policy review, the facility failed to ensure that social workers wrote progress notes for 7 of 8 active sample patients (A10, A15, A18, A19, L8, L10 and L11) that contained information about discharge planning. This failure impedes the treatment team's ability to assess or evaluate the patient's response to treatment and readiness for discharge.

Findings include:

A. Record Review

1. Patient A10 (admitted 8/8/12) had three social work progress notes written since admission. The notes were dated 8/8/12, 8/9/12, and 8/13/12. None of the notes included information related to discharge planning.

2. Patient A15 (admitted 7/28/12) had four social work progress notes written since admission. The notes were dated 7/30/12, 7/31/12, 8/6/12, and 8/7/12. None of the notes included information related to discharge planning.

3. Patient A18 (admitted 4/26/12) had ten social work progress notes in the past month. The notes were dated 7/11/12, 7/12/12, 7/16/12, 7/21/12, 7/23/12, 7/28/12, 7/30/12, 8/4/12, 8/6/12, and 8/11/12. None of these notes included information related to discharge planning.

4. Patient A19 (admitted 4/2/12) had ten social work progress notes in the past month. The notes were dated 7/9/12, 7/11/12, 7/18/12, 7/19/12, 7/25/12, 7/27/12, 8/1/12, 8/2/12, 8/9/12 and 8/10/12. None of these notes included information related to discharge planning.

5. Patient L8 (admitted 8/9/12) had two social work progress notes since admission. The notes were dated 8/10/12 and 8/13/12. None of the notes included information related to discharge planning.

6. Patient L10 (admitted 11/17/11) had ten social work progress notes in the past month. The notes were dated 7/11/12, 7/16/12, 7/19/12, 7/23/12, 7/25/12, 7/30/12, 8/2/12, 8/6/12, 8/8/12, and 8/13/12. None of these notes included any information related to discharge planning.

7. Patient L11 (admitted 7/23/12) had eight social work progress notes since admission. The notes were dated 7/24/12, 7/25/12, 7/26/12, 7/30/12, 8/2/12, 8/6/12, 8/9/12, and 8/13/12. None of the notes included information related to discharge planning.

B. Interview

In an interview on 8/14/12 at 1 PM, the Director of Social Work stated, "Yes, I see what you mean, we are not writing about discharge issues in the notes."

C. Policy Review

Facility policy CS-011 titled "Guidelines for Discharge Planning," and dated 03/02/10, states, "Discharge planning begins on admission."

Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 5 of 5 discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). Additionally, the physician dictation for 3 of 5 patient records (D1, D3 and D4) was completed after the scheduled outpatient appointment follow up date. These failures result in a lack of critical clinical information indicating the patient's level of psychiatric symptomatology and risk being available to aftercare providers.

Findings include:

A. Record Review

1. Patient D1 (discharged 6/1/12): The Discharge Summary dated 7/7/12 did not include any recommendations or interventions for the next treatment provider. The patient had an outpatient appointment scheduled on 6/4/12. The discharge summary was dictated 4 weeks later and was thus unavailable to outpatient providers.

2. Patient D2 (discharged 6/20/12): The Discharge Summary dated 7/6/12 did not include any recommendations or interventions for the next treatment provider. Patient D3 (discharged 6/28/12): The Discharge Summary dated 7/12/12 did not include any recommendations or interventions for the next treatment provider. The patient had an outpatient appointment scheduled on 7/3/12. The discharge summary was dictated on 7/12/12 and was thus unavailable to outpatient providers.

4. Patient D4 (discharged 6/5/12): The Discharge Summary dated 6/15/12 did not include any recommendations or interventions for the next treatment provider. The patient had an outpatient appointment scheduled on 6/5/12. The discharge summary was dictated on 6/15/12 and was thus unavailable to outpatient providers.

5. Patient D5 (discharged 6/21/12): The Discharge Summary dated 7/11/12 did not include any recommendations or interventions for the next treatment provider.

B. Interview

In an interview on 8/14/12 at 2:15 PM, when shown examples of the Discharge Summaries noted above, the Medical Director agreed with the findings and stated, "We don't have a section for that information in our reports. We should get these done before patients have an appointment."

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

I. Psychiatric Evaluations for 7 of 8 active sample patients (A15, A18, A19, L8, L10, L11 and L12), History and Physical (H&P) Examinations for 7 of 8 active sample patients (A10, A15, A18, A19, L10, L11 and L12), and 1 of 5 Discharge Summaries (D1) were completed in a timely manner. Additionally, 1of 8 active sample patient's Psychiatric Evaluation (L10) was completed by a Physician's Assistant (PA) against facility policy. These failures hamper the clinical staff's ability to fully utilize the skills and knowledge of the psychiatrist.

Findings include:

A. Policy Review

In the facility policy titled "Multi-Disciplinary Assessments," the following was noted:

1. "The following assessments will be completed on each patient/resident admitted within the corresponding time frame. 1. History and Physical-within 24 hours. 3. Psychiatric Evaluation (including MSE)-within 24 hours."

2. "Procedure; 2. Psychiatric Evaluation: the psychiatric evaluation shall be completed by a qualified psychiatrist, privileged under the professional staff organization to admit clients to Willow Crest Hospital Inc./Moccasin Bend Ranch."

B. Record Review

1. Patient A10, admitted 8/8/12, had a History and Physical Examination completed by a Physician's Assistant on 8/10/12. The H&P was not co-signed by a physician as of 8/14/12.

2. Patient A15, admitted 7/28/12, had a History and Physical Examination completed by a Physician's Assistant on 7/30/12. The H&P was co-signed by a physician on 7/30/12. The Psychiatric Evaluation was completed on 7/30/12.

3. Patient A18, admitted 4/26/12, had a History and Physical Examination performed by a Physician's Assistant on 4/28/12. The H&P was signed by the PA on 5/2/12 and co-signed by a physician on 4/30/12. The Psychiatric Evaluation was completed on 4/29/12.

4. Patient A19, admitted 4/2/12, had a History and Physical Examination performed by a Physician's Assistant on 4/3/12. The H&P was signed by the PA on 4/5/12 and co-signed by a physician on 4/6/12. The Psychiatric Evaluation was completed on 4/4/12.

5. Patient L8, admitted 8/9/12, had a Psychiatric Evaluation completed on 8/13/12. The Psychiatric Evaluation was countersigned by the Medical Director, not the physician performing the evaluation.

6. Patient L10, admitted 11/17/11, had a Psychiatric Evaluation completed by a Physician's Assistant on 11/18/11 and was signed by the PA on 11/21/11. The History and Physical Examination was completed by a Physician's Assistant on 11/21/11 and co-signed by a physician on 11/21/11.

7. Patient L11, admitted 7/23/12, had a History and Physical Examination performed by a Physician's Assistant on 7/24/12 and signed on 7/26/12. The H&) was co-signed by a physician on 7/25/12. The Psychiatric Evaluation was completed on 7/25/12.

8. Patient L12, admitted 8/8/12, had a History and Physical Examination performed by a Physician's Assistant on 8/10/12 and signed on 8/14/12. The H&P was co-signed by a physician on 8/10/12, one minute after it was transcribed. The Psychiatric Evaluation was completed on 8/10/12.

9. Patient D1, discharged 6/1/12, had a Discharge Summary dated 7/7/12 (7 days late).

C. Interview

In an interview on 8/14/12 at 2 PM, the Medical Director was shown the records noted in part B above. He agreed that the psychiatric evaluations were not completed within the time frames noted in the policy manual. He stated, "I didn't realize that the psych evals still needed to be done within 24 hours; I thought that was changed a while ago." When asked about a Physician Assistant performing psychiatric evaluations outside of his privileged credentials, the Medical Director stated, "We were told about that during a state survey last year."

II. Ensure that the social work assessments for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11 and L12) included conclusions and recommendations describing anticipated social work roles in treatment and discharge planning. This failure results in a lack of social work input to the interdisciplinary team for treatment planning. (Refer to B108)

III. Ensure that the Master Treatment Plans for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11 and L12) included physician interventions that were individualized based on assessed patient needs. In addition, the MTPs for 3 of 8 active sample patients (A10, A15, and L10) did not include individualized social work interventions, and the MTPs of 2 of 8 active sample patients (A10 and A15) did not include individualized nursing interventions. Instead, the listed interventions were generic monitoring and assessment functions. These failures result in treatment plans that do not reflect a comprehensive, integrated and individualized approach to multidisciplinary treatment. (Refer to B122)

IV. Ensure that all patients in the acute phase of psychiatric illness received acute psychiatric care. Five of 8 active sample patients (A15, A18, A19, L10 and L11) were designated as residential treatment patients but were housed on acute care units at the time of survey. These patients received a less intense level of care than patients designated as "acute care." They received less individual and family therapy sessions per week than the acute care patients. They also received fewer psychiatrist visits per week than acute care patients. This failure places patients at risk for less than adequate treatment. (Refer to B125-I)

V. Ensure that dignity and privacy were provided for 5 of 8 active sample patients (A10, A15, A18, A19, and L8) and 13 additional non-sample patients (A1, A2, A6, A7, A8, A9, A12, A13, A14 A16, A20, L6 and L14). These patients were required to sleep on the floor in the hallway overnight on a regular basis. The patients were fully exposed to light/noise and experienced no privacy during their sleeping hours. This failure can contribute to vulnerability and anxiety, and is not conducive to developing feelings of safety and self-esteem. (Refer to B125-II)

VI. Ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 5 of 5 discharged patients whose records were reviewed (D1, D2, D3, D4, and D5). Additionally, the physician dictation for 3 of 5 patient records (D1, D3 and D4) was completed after the scheduled outpatient appointment follow up date. These failures result in a lack of critical clinical information indicating the patient's level of psychiatric symptomatology and risk being available to aftercare providers. (Refer to B134)

Based on personnel record review and interview, the facility failed to employ a Director of Nursing (DON) with a Master's Degree in Psychiatric Mental Health Nursing, that was qualified by education and experience in the care of the mentally ill, or that had documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing. This failure results in the facility not having a qualified nursing director to manage psychiatric/mental health nursing care.

Findings include:

A. Personnel Record Review:

On 8/13/12 at 1 PM, the nurse surveyor reviewed the personnel record of the Director of Nursing and found that the DON graduated from an Associate Degree program in nursing in 2008. The record revealed that the Director of Nursing had 4 years of experience in psychiatric nursing and had been in the DON position since April 2012. There was no documentation for any consultant services from a Master's prepared nurse.

B. Interview:

In an interview on 8/14/12 at 8 AM, the Director of Nursing stated, "I have an Associate Degree, no Master's Degree. I do not have any consultations with a Master's prepared nurse." She stated, "I have worked 4 years in psychiatric nursing since graduation in 2008."

Based on record review, interview and policy review, the Director of Nursing failed to monitor and assure that nursing interventions on the Master Treatment Plans of 2 of 8 active sample patients (A10 and A15) were individualized, based on the patients' assessed needs. The listed nursing interventions on these patients' MTPs were generic monitoring and assessment functions. This failure results in treatment plans that do not reflect a comprehensive, integrated and individualized approach to multidisciplinary treatment for patients.

Findings include:

A. Record Review

1. For sample patient A10, the Master Treatment Plan, dated 8/8/12, had the following generic nursing intervention for the identified problem "Suicidal Ideation":
"Meet 1:1 with patient 3-5 minutes to explore triggers to suicidal thoughts/threats and teach coping skills."

2. For sample patient A15, the Master Treatment Plan, dated 7/30/12, had the following generic nursing intervention for the identified problem, "Harm to Self":
"Meet 1:1 with patient 3-5 minutes to explore triggers to suicidal thoughts and teach coping skills."

B. Interview

In an interview on 8/15/12 at 8:25 AM, the Director of Nursing stated, "I can see that interventions are not individualized."

C. Policy Review

Facility policy CS-102 titled "Treatment Planning" and dated 03/02/12, states, "It is the policy of Willow Crest Hospital/Moccasin Bend Ranch to provide responsive, individualized, interdisciplinary treatment planning for patients." In addition, the policy states, "Interventions will be noted with a brief statement on the form next to the appropriate discipline..."

Based on record review, policy review and interview, the Clinical Director (Administrator responsible for Social Work) failed to:

I. Ensure that the psychosocial evaluations of 2 of 8 active sample patients (L8 and L12), which were completed by clinicians who were not trained as social workers, were reviewed and co-signed by a trained social worker. Failure to assure supervision and oversight for social work staff places patients at risk for not receiving the full benefit of care from social services.

Findings include:

A. Record Review

1. Patient L8: In a psychosocial evaluation dated 8/12/12, the social work portion was completed by an LPC (Licensed Psychiatric Counselor) and not co-signed by a social worker.

2. Patient L12: In a psychosocial evaluation dated 8/11/12, the social work portion was completed by an LPC (Licensed Psychiatric Counselor) and not co-signed by a social worker.

B. Interview

In an interview on 8/14/12 at 1 PM, when shown the psychosocial evaluations for Patients L8 and L12, the Clinical Director agreed that the evaluations were not performed by a social worker and were not co-signed by a social worker.

II. Ensure the provision of social work assessments that included conclusions and recommendations describing anticipated social work roles in treatment and discharge planning for 8 of 8 active sample patients (A10, A15, A18, A19, L8, L10, L11 and L12). This failure results in a lack of input to the interdisciplinary team for treatment planning. (Refer to B108)

III. Ensure that the Master Treatment Plans for 3 of 8 active sample patients (A10, A15, and L10) included social work interventions that were individualized for patients, based on the patients' assessed needs. This failure results in treatment plans that do not reflect a comprehensive, integrated and individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A10: The Master Treatment Plan dated 8/8/12 included the following generic social work interventions:
For the identified problem "Suicidal Ideation": "Individual and family therapy sessions to address dysfunctional communication patterns and teach assertiveness communication utilizing 'I' statements."

2. Patient A15: The Master Treatment Plan dated 7/30/12 included the following generic social work interventions:
For the identified problem "Harm to self": "Individual and family sessions to identify triggers and solutions to the problem."

3. Patient L10: The Master Treatment Plan dated 7/19/12 included the following generic social work interventions:
For the identified problem "Defiance": "Individual and family sessions to provide support and encouragement."
For the identified problem, "Reactive attachment disorder": " Individual and family sessions to provide support, validation, and encouragement."

B. Interview

In an interview on 8/14/12 at 12:50 PM, the Clinical Director (Administrator responsible for Social Work) stated, "I see what you mean. The interventions are not specific."

IV. Ensure that social workers' progress notes for 7 of 8 active sample patients (A10, A15, A18, A19, L8, L10 and L11) contained information about discharge planning. This failure impedes the treatment team's ability to assess or evaluate the patient's response to treatment and readiness for discharge. (Refer to B128)