HospitalInspections.org

Based on document review and interview, the facility failed to ensure adequate numbers of qualified staff to provide active treatment to the patient population. Specifically the facility failed to:

I. Ensure the availability of a Clinical Director (Medical Director) who meets the training and experience requirements for board examination in psychiatry. This failure compromises the quality and appropriateness of the supervision available to staff in their assessment and treatment of patients. (Refer to B143)

II. Ensure the employment of a Director of Nursing (DON) with a Master's Degree in psychiatric nursing, ongoing training in psychiatric nursing, or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing. This failure compromises the quality of nursing care, and potentially results in an unsafe environment for patients. (Refer to B147)

III. Ensure the availability of a registered nurse on each day, evening, and night shift, seven days a week. Review of a week's staffing pattern revealed that for many days, there were no evening or night shift RNs present, and on two days of the reviewed week, there were no RNs present for any shift of the 24-hour period. This staffing pattern results in the lack of active treatment provided by registered nurses, lack of professional oversight and supervision of Licensed Practical Nurses with delegated nursing functions, and lack of direction and supervision of Certified Nursing Assistants in the provision of nursing care. (Refer to B149)

IV. Ensure that there is a Director of Social Work who has oversight responsibility for evaluating the quality and appropriateness of social services. Lack of social work monitoring can result in major gaps in the provision of social services. (Refer to B152)

V. Ensure adequate numbers of qualified social work staff to provide discharge planning. This deficiency can result in failure to plan aftercare for all significant problems identified during hospitalization and can lead to incomplete and inconsistent aftercare treatment. (Refer to B155)

VI. Ensure adequate numbers of activity therapy staff to provide activity therapy assessments, participate in treatment planning, and offer therapeutic activities. Failure to provide trained activity therapy staff results in a lack of appropriate structured activities, potentially hampering patients' progress in obtaining their optimal level of psychosocial and physical functioning. It also can delay patients' successful return to the community. (Refer to B158)

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an estimate of intellectual functioning for 6 of 12 active sample patients (A1, A3, A5, A6, A8 and A9). This compromises the database from which diagnoses are determined and fails to provide an objective baseline for future comparisons.

Findings include:

A. Record review

1. Patient A1: In a psychiatric evaluation dated 3/8/11, there was no estimate of intellectual functioning.

2. Patient A3: In a psychiatric evaluation dated 3/22/11, there was no estimate of intellectual functioning.

3. Patient A5: In a psychiatric evaluation dated 3/31/11, there was no estimate of intellectual functioning.

4. Patient A6: In a psychiatric evaluation dated 4/14/11, there was no estimate of intellectual functioning.

5. Patient A8: In a psychiatric evaluation dated 4/14/11, there was no estimate of intellectual functioning.

6. Patient A9: In a psychiatric evaluation dated 4/14/11, there was no estimate of intellectual functioning.

B. Staff interview

During an interview on 5/3/11 at 9:30a.m., which included a discussion of the lack of findings on intellectual functioning on the psychiatric evaluations, Physician 1 stated, "Sometimes it is not done."

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an inventory of patient assets in descriptive, non-interpretive fashion for 6 of 12 sample patients (A1, A3, A4, A5, A9 and A10). This deficiency results in a lack of information to guide staff in developing a plan of treatment for the patient.

Findings include:

A. Record review

1. Patient A1: In a psychiatric evaluation dated 3/8/11, assets were not addressed.

2. Patient A3: In a psychiatric evaluation dated 3/22/11, assets were not addressed.

3. Patient A4: In a psychiatric evaluation dated 3/31/11, assets were not addressed.

4. Patient A5: In a psychiatric evaluation dated 3/31/11, assets were not addressed.

5. Patient A9: In a psychiatric evaluation dated 4/14/11, assets were not addressed.

6. Patient A10: In a psychiatric evaluation dated 4/14/11, assets were not addressed.

B. Staff Interview

During an interview on 5/3/11 at 9:30a.m., which included a discussion of the lack of documented patient assets on the psychiatric evaluations, Physician 1 said, "Sometimes it is not done."

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) for12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13) that identified individualized patient-related short-term goals, stating what the patient would do to lessen the severity of problems identified on admission. The treatment plans contained goal statements written as staff interventions instead of patient outcome behaviors. In addition, there was no long-term goal that identified what the patient would achieve by the time of discharge. Failure to identify individualized goals hampers the treatment team's ability to determine whether the treatment plan is effective and/or needs revision.

Findings include:

A. Record Review (dates of MTPs in parentheses)

The Master Treatment Plans, called the "Individual Plan of Care (IPOC)/Individual Treatment Plan" by the facility, were reviewed for the following sample patients: A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 (4/5/11), A9 (4/14/11) , A10 (4/15/11), A11 (4/17/11), A12 (4/20/11) and A13 (4/27/11). There were no long-term goals on any of the treatment plans. The following staff interventions/goals were listed as patient goals under the section entitled "Goals/measurable objective/criteria for achievement":

1. Patient A1, A6, A7, and A8: Psychological - "Client will be assessed with psychological testing." Medical - "Client will be seen by Medical Director and staff to address medical issues [MD's name]." Psychiatric - "Client will be assesses [sic] by psychiatrist to evaluate mental health issues and monitor any such meds that are prescribed (MD's name]."

2. Patient A3: Medical: "Client will be seen by Medical Director and staff to address medical issues that arise during treatment." PMA [Psychiatric Medical Assistant]: "Client will be assessed by Psychiatrist for issues with Depression and medication monitoring. Client will take medication as prescribed by the doctor." Psych [Psychologist]: "Client will be assessed with psychological testing (psychologist)."

3. Patient A4, A5, and A12: Medical/ [MD's name]: "Treat any medical disorder." PMA/ [Psychiatrist's name]: "Diagnose and treat psychiatric disorders." Case Management/ [staff's name]: "Coordinate services needed." "Psych Testing/ [Psychologist name]": Perform psychological testing as needed."

4. Patient A9, A10, and A13: Medical - "Client will be seen by Medical Director and staff to address medical issues that arise during treatment." PMA [Psychiatric Medical Assistant] - "Client will be assessed by Psychiatrist." Psychiatrist [sic] - "Client will receive psychological testing [staff' name]." Medical - "Client will be referred to a Cardiologist for assessment/treatment." CM [Case Management] - "Coordinate needed services to support treatment." The medical history and physical examination of these patients completed at the time of admission did not identify any history of cardiac problems or any cardiac problems found on examination.

B. Staff Interviews

1. In an interview on 5/3/11 at approximately 11:40a.m. with RN1 and the Director of Nursing (DON), the sample patients' treatment plans, including the "Individual Plan of Care (IPOC) /Individual Treatment Plan" and the "Interdisciplinary Treatment Plan" were reviewed. The DON pointed to the document entitled the "Individual Plan of Care (IPOC) /Individual Treatment Plan" and stated that this plan is the Master Treatment Plan.

2. In an interview on 5/3/11 at 2:15p.m., the treatment plans for Patients A1 and A4 were reviewed with Counselor 1 for content under the section for Medical, Psychiatric Medical Assistant, Case Management, and Psychologist. Counselor 1 agreed that items listed under the goals section of the treatment plan were staff interventions/goals rather than what the patient would do to lessen the severity of problems identified upon admission.

3. During an interview on 5/4/11 at 9:40a.m., Counselor1 agreed that there were no long-term goals identified on the facility's treatment plans. Counselor1 stated, "It is hard to establish long-term goals except for educational strategies to stay drug free and establish relationships with family. They (patients) are only here for six weeks. The Department of Alcohol and Drugs only require short-term goals."

Based on observation, document review, and interview, the facility failed to:

I. Provide Master Treatment Plans that included interventions with a specific focus and purpose of treatment and that addressed the individual needs of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13). Specifically, the treatment plans contained a list of treatment modalities (individual therapy, substance abuse counseling, and family therapy) without a specific focus. This failure hampers staff's ability to provide consistent and effective treatment related to presenting problems and goals identified on the treatment plans.

II. Provide Master Treatment Plans for 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13) that included treatment modalities/interventions for all clinical disciplines involved in active treatment. The treatment plans failed to include any interventions assigned to registered nurses. This results in plans that do not reflect a comprehensive and interdisciplinary approach to providing active treatment for patients.

III. Ensure that group therapy sessions listed on the Adolescent Unit Schedule and attended by 7 of 12 of active sample patients (A1, A3, A4, A5, A10, A12, and A13) on 5/2/11 and 5/3/11 were included on the patient's Master Treatment Plans. This failure results in the lack of direction for clinicians regarding the specific treatment approaches and focus of treatment for each individual patient, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

I. Failure to Specify Focus of Treatment

A. Record Review (dates of MTPs in parentheses)

The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the following sample patients were reviewed: A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 (4/5/11), A9 (4/14/11), A10 (4/15/11), A11 (4/17/11), A12 (4/20/11) and A13 (4/27/11). The following interventions, labeled "Type of Service," were on all of the treatment plans: "SAC" [Substance Abuse Counseling], "it" [Individual Therapy], "ft" [Family Therapy] to be delivered by "MMYT" [Medically Monitored Youth Treatment] Counselors or "Primary Counselors/SAC Counselors." These interventions did not state the focus of treatment based on the presenting problems and/or goals of each patient.

B. Staff Interview

In an interview on 5/3/11 at 2:15p.m., Counselor1 acknowledged that the interventions under the "Type of Service" section of the Master Treatment Plans did not include a specific focus of treatment for individual patients.

II. Failure to include all Disciplines on Treatment Plan

A. Record Review (MTP dates in parentheses)

The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the following patients were reviewed: A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 (4/5/11), A9 (4/14/11), A10 (4/15/11), A11 (4/17/11), A12 (4/20/11) and A13 (4/27/11). None of the plans contained treatment modalities/interventions assigned to registered nurses.

B. Staff Interviews

During an interview on 5/2/11 at 2:10p.m., which included a review of the treatment plans for patients A1 and A3, the Director of Nursing acknowledged that interventions for registered nurses were not included on the Master Treatment Plans. The DON stated that nursing interventions were only included on the initial treatment plan (plan completed at the time of admission.

III. Failure to Include Treatment Interventions Offered

A. Observations

1. During an observation on 5/2/11 from 12:10 to 1:00p.m., sample patients A1, A3, A4, and A5 attended a group conducted by Counselor1. The group session focused on the abuse and risk associated with the "Triple Cs" [Coricidin HBP Cough and Cold].

2. The surveyors observed a group listed on the Adolescent Schedule as "Group Therapy" on 5/3/11 from 12:45p.m. to 1:30p.m. The group was attended by sample patients A1, A3, A4, A10, A12 and A13.

B. Record and Document Review

1. Review of the Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for patients A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A10 (4/15/11), A12 (4/20/11) and A13 (4/27/11) revealed that the above groups attended by these patients were not included on their treatment plans.

2. The Adolescent Schedule listed "Group Therapy" scheduled Monday through Friday from 12:10p.m. - 2:00p.m. and 2:10p.m. to 3:30p.m. and "Rec. [recreation] Therapy" Monday through Thursday and Saturday and Sunday from 3:30p.m. through 4:30p.m. These modalities/interventions were not included on the above patients ' treatment plans.

C. Staff Interview

During an interview on 5/3/11 at 2:15p.m., Counselor1 acknowledged that the medication-related group conducted on 5/2/11 was not on the treatment plans for patients A1, A3, A4 and A5. Counselor1 stated that this group is "drug education", not "group therapy." Counselor1 also stated that the substance counseling on the treatment plans included the groups listed on the schedule. No specific groups were identified.

Based on record review and interview, the facility failed to ensure that the primary counselors responsible for counseling interventions were identified by name on the Master Treatment Plans of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11 A12, and A13). The treatment plans listed the discipline rather than the name and discipline of the counselor responsible for each intervention. This practice potentially results in ineffective monitoring of each primary counselor's accountability for interventions.

Findings include:

A. Record Review (MTP dates in parentheses)

The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the following patients were reviewed: A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 (4/5/11), A9 (4/14/11, A10 (4/15/11), A11 (4/17/11), A12 (4/20/11), and A13 (4/27/11). The review revealed that the name of the primary counselor responsible for the interventions listed was not included on any of the patients' treatment plans.

B. Staff Interview

During an interview on 5/3/11at 10:50a.m., Counselor II confirmed that the name of the assigned counselors were not recorded for interventions listed on the sample patients ' treatment plans. Counselor II stated that counselors are assigned to different groups, and therefore do not include their names on individual patients' treatment plans.

Based on document review and interview, the facility failed to employ a Medical Director who meets the training and experience requirements for board examination in psychiatry. This failure compromises the quality and appropriateness of the supervision available to staff in their assessment and treatment of patients.

Findings include:

A. Document review

The Curriculum Vitae of the Medical Director provided by the facility showed that the Medical Director is a Fellow in the American Society of Addiction Medicine and is a Fellow in the American College of Obstetrics and Gynecology, but has not completed a psychiatric residency program.

B. Staff interview

In an interview on 5/2/11 at 4:00p.m., the Medical Director acknowledged that he did not have psychiatry residency training.

Based on record review and staff interview, the Medical Director failed to ensure adequate supervision and oversight of staff conducting psychiatric evaluations and treatment planning. Specifically, the Medical Director failed to:

I. Ensure that the psychiatric evaluations of 6 of 12 active sample patients (A1, A3, A5, A6, A8 and A9) included an estimate of intellectual functioning. This failure compromises the database from which diagnoses are determined and does not establish a baseline for future comparison. (Refer to B116)

II. Ensure that the psychiatric evaluations of 6 of 12 sample patients (A1, A3, A4, A5, A9 and A10) included an inventory of patient assets in descriptive non-interpretive fashion. This deficiency results in lack of information to guide staff in developing a plan of treatment for the patient. (Refer to B117)

III. Ensure that the Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13) identified individualized patient-related short-term goals, stating what the patient would do to lessen the severity of problems identified on admission. In addition, there were no long-term goals that identified what the patient would achieve by the time of discharge. Failure to identify individualized goals hampers the treatment team's ability to determine whether the treatment plan is effective and/or needs revision. (Refer to B121)

IV. Ensure that the Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13) provided interventions that included a specific focus and purpose of treatment that addressed the individual needs of patients. This failure hampers the staff's ability to provide consistent and effective treatment related to presenting problems and goals identified on the treatment plans. (Refer to B122-I)

V. Ensure that both the name and discipline of the person responsible for each intervention identified on the Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13). This practice potentially results in ineffective monitoring of each staff's accountability for interventions. (Refer to B123)

Based on document review and staff interview, the facility failed to employ a Director of Nursing (DON) with a Master's Degree in psychiatric nursing, ongoing training in psychiatric nursing, or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing.

Findings include:



1. A review of the DON's curriculum vitae revealed that she had a Bachelor's of Science in Nursing. The DON was not able to produce evidence of training in psychiatric nursing except for 5.75 Continuing Education (CE) credits for attending an annual convention regarding "Working with Troubled Teens" on April 8, 2011 and online credits of 13.5 CEs for psychiatric topics earned from 2009 to 2011.

2. During an interview on 5/4/11 at 9:40a.m., the DON acknowledged that she did not have documentation of training/education in psychiatric nursing other than the CE credits above, and that she did not have access to a registered nurse with a Master's Degree in Psychiatric Nursing to provide consultation.

Based on observation, record review, and interview, the Director of Nursing (DON) failed to provide adequate supervision and oversight of the nursing staff to ensure quality psychiatric nursing care. Specifically, the DON failed to:

I. Ensure that the Master Treatment Plans of 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, & A13) included modalities/interventions by registered nurses. None of the Master Treatment Plans for the sample patients listed nursing interventions. This results in treatment plans that do not reflect a comprehensive and interdisciplinary approach to providing active treatment for patients.

Findings include:

A. Record Review (MTP dates in parentheses)

The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the following patients were reviewed: A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 (4/5/11), A9 (4/14/11), A10 (4/15/11), A11 (4/17/11), A12 (4/20/11), and A13 (4/27/11). None of the treatment plans contained treatment modalities/interventions assigned to registered nurses.

B. Staff Interviews

During an interview, on 5/2/11 at 2:10p.m. with the Director of Nursing, the treatment plans for patients A1 and A3 were reviewed. The Director of Nursing confirmed that interventions for registered nurses were not included on the patient's Master Treatment Plans. The Director of Nursing stated that nursing interventions were only included on the initial treatment plan (plans completed at the time of admission).

II. Ensure the availability of a Registered Nurse on each day, evening, and night shift, seven days a week. Review of a week's staffing pattern revealed that for many 24-hour periods, there were no evening or night shift RNs present, and for two days of the reviewed week, there were no RNs present on any shift of the 24-hour period. This staffing pattern results in the lack of active treatment provided by registered nurses, lack of supervision for Licensed Practical Nurses with delegated nursing functions, and lack of direction and supervision of Certified Nursing Assistants in the provision of nursing care. (Refer to B149)

III. Ensure that documentation showed evidence of active treatment delivered by Registered Nurses for 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13). There was no written evidence that RNs were involved in providing active treatment measures such as patient teaching and medication education. In addition, because there were shifts when Registered Nurses were not available, LPNs performed nursing functions that were not within their scope of practice. These failures result in lack of professional nursing care being provided to and available for patients, potentially delaying their discharge.

Findings include:

A. Record Review

1. Nursing Assessments were completed by LPNs for two active sample patients (A3 and A11) and one non-sample patient (B1). The LPN completed all sections of the Nursing Assessment including the "Interdisciplinary Treatment Plan." This was the initial plan formulated at the time of admission and attached to the Nursing Assessment. To complete this plan, the LPN had to analyze the data collected, determine the problems to be addressed during hospitalization, and formulate treatment goals for patient care. These functions are not within the scope of practice for LPNs according to the Advisory Opinion number 21 from the South Carolina Board of Nursing, last reviewed May 2006.

2. Patient teaching and medication education sessions provided to the adolescent patients by Registered Nurses were not included on the patients' Master Treatment Plans or the Unit Schedule, and were not documented in the medical records as being provided by registered nurses.

B. Staff Interviews

1. During an interview, on 5/2/11 at 2:10p.m. with the Director of Nursing, the medical records for Patients A1 and A4 were reviewed. When the surveyor asked about patient teaching and medication education, the Director of Nursing stated that nurses do patient teaching with adolescents and discuss their medications with them. The Director of Nursing stated, "I know that if it is not documented, it is not done."

2. In an interview on 5/3/11 at approximately 10:20a.m., the Director of Nursing agreed that functions such as formulating the "Interdisciplinary Treatment Plan" which was the initial treatment plan, were not within the scope of practice for LPNs. The Director of Nursing stated, "LPNs are only responsible for collecting data for the Nursing Assessment." However, she also stated that completing this plan included identifying problems and writing treatment goals based on data collected for Nursing Assessments.

3. In an interview on 5/3/11 at 4:00p.m., LPN1 stated that LPNs complete all sections of the Nursing Assessment, including the "Interdisciplinary Treatment Plan" (Initial Treatment Plan) which involves identifying problems and writing the treatment goals. LPN1 also stated that LPNs complete the Suicide Assessment.

Based on a document review, staff interviews, and observations, the facility failed to ensure the availability of a Registered Nurse for each day, evening, and night shift, seven days a week. Review of a week's staffing pattern revealed that for many 24-hour periods, there were no evening or night shift RNs present, and for two days of the reviewed week, there were no RNs present on any shift of the 24-hour period. This staffing pattern results in the lack of active treatment provided by registered nurses, lack of professional oversight and supervision of Licensed Practical Nurses with delegated nursing functions, and lack of direction and supervision of Certified Nursing Assistants in the provision of nursing care.

Findings include:

1. A review of the staffing data for 4/26/11 to 5/2/11 revealed that there was no RN assigned to the Adolescent Unit for each shift. [This unit was the only inpatient unit in the facility.] The analysis of the staffing data revealed no RN coverage on the following shifts:

a. 4/26/11: No RN coverage on all three shifts with a census of 13 Adolescents.

b. 4/27/11: No RN coverage on the night shift with a census of 13 Adolescents.

c. 4/28/11 and 4/29/11: No RN coverage on the evening or night shifts (census: 14 on 4/28/11; 15 on 4/29/11).

d. 4/30/11 and 5/1/11: No RN coverage on all three shifts with a census of 15 Adolescents

e. 5/2/11: No RN coverage on the evening and night shifts with a census of 15 Adolescents.

2. In an interview on 5/3/11 at approximately at 10:20 a.m., the Director of Nursing stated that the staffing noted above was the usual staffing pattern for the Adolescent Unit.

3. Review of the "Nursing Needs Assessment" Form completed on 5/3/11 for the Adolescent Unit revealed 2 patients at risk of suicide ["Cutters [self mutilating behaviors] prior to admission"] and 1 patient on diabetic checks. The average number of admissions per week was 2.5 patients. The average number of discharges per week was 2.5 patients.

4. Additional census data submitted on 5/4/11 showed that the Adolescent unit had 13 admissions and 11 discharges during April 2011.

Based on record review and interview, the facility failed to designate a Director of Social Services who had oversight responsibility for evaluating the quality and appropriateness of social services provided in the facility. This results in lack of a discipline-specific process to ensure quality social work practices and/or plans of corrections for operational problems.

Findings include:

A. Document Review

A review of the facility's organizational chart revealed that the position for Director of Social Services was not included on the chart.

B. Staff Interview

1. In an interview on 5/3/2011 at 1:15p.m., the Deputy Director of the Tri County Commission on Alcohol and Drug Abuse stated, "There is no appointed Director of Social Services employed at the McCord Treatment Center. However, the current Director of Social Work at the Dawn Center provides minimal support to primary counselors (official title "Clinical Counselor") by attending treatment team meeting once a week" and giving "input on community resources for adolescence." The primary counselors are not social workers.

2. In an interview on 5/3/2011 at 1:45p.m., the Director of Social Work at the Dawn Center stated, "I only provide consultation to the treatment team on the adolescent unit at Mc Cord Treatment Center. The Deputy Director provides clinical supervision to the counselors on the adolescent unit. I don't provide clinical supervision to anyone." The Deputy Director has a B.S. degree in Psychology and an M.A. in Rehabilitation Counseling, not a Masters degree in social work.

Based on record review and staff interviews, the facility failed to provide adequate discharge planning for 12 of 12 active sample patients (A1, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12 and A13). Failure to plan aftercare for significant problems identified during hospitalization can result in incomplete and inconsistent aftercare treatment.

Findings include:

A. Record Review

1. Patient A1 was a 14 year old admitted for treatment of chronic Post Traumatic Stress Disorder (PTSD), Major Depression, Attention Deficit Hyperactivity Disorder (ADHD), and alcohol abuse. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 3/4/11.

2. Patient A3 was a 16 year old admitted for treatment of depression, chronic PTSD, borderline personality traits, and drug usage. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 3/22/11.

3. Patient A4 was a 16 year old admitted for treatment of Anxiety, ADHD, rule out PTSD, and probation violation. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 3/31/11.

4. Patient A5 was a 17 year old admitted from another treatment facility for treatment of depression following the death of a friend, and for problem behaviors associated with alcohol use. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 3/22/11.

5. Patient A6 was a 17 year old admitted due to behavioral problems related to marijuana use. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/5/11.

6. Patient A7 was a 17 year admitted for treatment of depression, anxiety, ADHD, and alcohol abuse. Conclusions and recommendations regarding discharge planning were not included in on the Clinical Assessment Summary dated 4/5/11.

7. Patient A8 was a 17 year old referred from another treatment facility for treatment of depression and ADHD. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/6/11.

8. Patient A9 was a 16 year old admitted for treatment of Conduct Disorder, ADHD, and drug use. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/14/11.

9. Patient A10 was a 16 year old admitted for treatment of rapid mood swings, ADHD and continued use of marijuana and other substances while in treatment. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/15/11.

10. Patient A11 was a 16 year old admitted to inpatient due to continued use of drugs while in treatment. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/17/11.

11. Patient A12 was a 17 year old referred from another treatment facility for treatment of anxiety, depression, drug use, and charges of second-degree burglary. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/20/11.

12. Patient A13 was a 17 year old referred by the court for treatment of oppositional defiant disorder, anxiety disorder, ADHD, and poly-substance dependence. Conclusions and recommendations regarding discharge planning were not included on the Clinical Assessment Summary dated 4/26/11.

13. The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the 12 sample patients also were reviewed (dates of plans in parentheses): A1 (3/4/11); A3 (3/22/11); A4 (3/31/11); A5 (3/31/11); A6 (4/5/11); A7 (4/5/11); A8 (4/5/11); A9 (4/14/11); A10 (4/15/11); A11 (4/17/11); A12 (4/20/11); and A13 (4/27/11). None of the treatment plans contained social work interventions for discharge planning.

B. Staff Interviews

1. In an interview on 5/3/11 at 10:50a.m., Counselor II stated, "There is no documentation on the Clinical Assessments or Master Treatment Plans about discharge planning."

2. In an interview on 5/3/2011 at 1:15p.m., the Deputy Director of Tri County Commission on Alcohol and Drug Abuse stated, "There are no social work interventions for discharge planning on the Master Treatment Plans because there are no social workers on staff."

Based on record and document review and staff interview, the facility failed to employ any therapeutic activity staff. There were no activity therapists to complete activity therapy assessments, ensure activity therapy participation in treatment planning, or offer therapeutic activities. Activities were conducted by non-certified activity personnel that included Certified Nursing Assistants, Registered Nurses, and Primary Substance Abuse Counselors. Failure to provide trained activity therapy staff results in a lack of appropriate structured activities, potentially hampering patients' progress in obtaining their optimal level of psychosocial and physical functioning. This also can delay patients' successful return to the community.

Findings include:

A. Record and Document Review

1. The Master Treatment Plans ("Individual Plan of Care (IPOC)/Individual Treatment Plan") for the following patients were reviewed (dates of plans in parentheses): A1 (3/4/11), A3 (3/22/11), A4 (3/31/11), A5 (3/31/11), A6 (4/5/11), A7 (4/5/11), A8 4/5/11), A9 (4/14/11, A10 (4/15/11), A11 (4/17/11), A12 (4/20/11) and A13 (4/27/11). The review revealed no activity therapy plans for any of the patients

2. The "Treatment Schedule" listed "Recreational Therapy" at 3:30p.m. - 4:30p.m. Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday. These recreational groups were not included on the Master Treatment Plans of any of the 12 active sample patients.

3. The facility's organizational chart included no position for Activity Director or therapeutic activity staff.

B. Staff Interviews

1. In an interview on 5/4/11 at 9:35a.m., the Director of Nursing informed the surveyors that the hospital did not have a Director of Activity Therapy or any activity therapy staff. The DON stated that the nursing staff (Certified Nurse Assistants or Registered Nurses) was providing some recreational activities.

2. In an interview 5/3/11 at 9:50a.m., Counselor I stated, "There is not an activity assessment completed. The Medical Director lets us know in treatment team meeting what the physical restrictions are for the patients."

3. In an interview on 5/2/11 at 11:00a.m., the Deputy Director of the Tri County Commission on Alcohol and Drug Abuse stated that he serves as the Activity Director, but that he does not do any formal activity assessments for patients because he does have the credentials to do this.