HospitalInspections.org

Based on observations, staff interview and review of documentation, the Hospital failed to have an effective governing body who is legally responsible for the conduct of the hospital. Finding include:

During interview on 1/13/15 at 1:00 P.M. the chief operating officer (CEO)/owner stated that she is the governing body and is responsible for the overall conduct of the hospital. She further stated that the Governing Body bylaws and the Medical bylaws are incorporated into one document entitled Professional Staff Bylaws and are approved by her as the governing body.

The governing body failed to effectively ensure the hospital:

1. Has an effective Quality Assessment and Performance Improvement Program which is clearly defined, implemented and maintained. (Please see A0263, A0273, A0283 , A0297 and A0309)

2. Has an organized medical staff that operates under bylaws approved by the governing body, and is responsible for the quality of medical care provided to patients by the hospital. (Please refer to A0338, A0340, A0347, A0355, A0357, A0358)

3. Has an active program for the prevention, control, and investigation of infections and communicable diseases. (Please refer to A0747, A0748, A0749, A0756).

Based on documentation review, observation and staff interview, the hospital failed to develop an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that reflected the complexity of the hospital's organization.

Finding include:

1. During the survey, the Conditions for Governing Body, Medical Staff, Nursing Services and Infection Control were found not met. The Hospital's Quality Assurance Program failed to identify and address significant findings to improve health outcomes as it relates to these areas. (Please refer to A-043; A-338; A-385; A-747).

2. The hospital failed to ensure that its QAPI (Quality Assurance Performance Improvement) Program Scope included quality assurance and performance improvement evaluations for services provided by the medical staff. There was no mechanism in place to insure that these services were provided in a safe and effective manner. (Please see A-338)

3. The hospital failed to ensure that the Program measured, analyzed, and tracked quality indicators of care and operations of the Hospital which included over-seeing the contracted services for medical waste removal and laundry services. (Please see A-0273)

4. The Hospital failed to take action on identified opportunities for improvement which included decreasing the risk of an influenza outbreak and monitoring patient compliance rates of attendance at groups. (Please see A-0283)

5. The hospital has not conducted any performance improvement projects and the governing body failed to define this requirement in the Quality Management Program policy, (Please see A-0297 and A-0309)

Based on document review and interview the Hospital failed to have an organized medical staff that operates under bylaws approved by the governing body, and is responsible for the quality of medical care provided to patients by the hospital. Findings include:

1. The Hospital failed to re-evaluate the competency for 1 of 5 Physicians (Physician #2) who was on call for the hospital and not currently educated, trained or had evidence of competency in the diagnosis and treatment of psychiatric patients.

Please refer to A340.

2. Review of the Senior Management meeting minutes and interview with the Medical Director on 1/13/15, indicated the medical staff is not well organized and accountable to the governing body for the quality of the medical care provided to the patients.

Please refer to A347.

3. Review of the credential files and interview with the Credentialing Coordinator on 1/13/15, indicated the Hospital failed to ensure that practitioner's privileges were signed by the appropriate staff and were related to their appointment for 2 of 5 practitioners (Physician #2 and Certified Registered Nurse Practitioner #1).

Please refer to A355.

4. Review of the credential files on 1/13/15 and interview with the Director of Human Resources on 1/14/15 for 1 of 5 practitioners (Physician #2), the Hospital failed to adhere to the qualifications for the continuation of hospital privileges and had no corrective plan for the unsatisfactory performance.

Please refer to A357.

5. Review of the Medical Bylaws and interview with the Administrator on 1/14/15, indicated the hospital failed to ensure that the medical bylaws included the requirement for the timely completion of history and physical examinations for each patient.

Please refer to A358.

Based on observations, review of policies and procedures, and interviews, the Hospital failed to provide an active program for the prevention, control, and investigation of infections and communicable diseases. Findings include:

1. Observations and staff interviews, on 1/12/15, 1/13/15, and 1/14/15 revealed the Hospital failed to ensure contracted services for medical/biohazardous waste removal were provided in a safe and effective manner.

Please refer to A713.

2. Observations on 1/12/15 and 1/14/15, and interview with the Infection Control Nurse (ICN) at 10:45 A.M., on 1/13/15, revealed that the Hospital failed to provide a qualified ICN and ensure that staff adhered to standards of IC practice for hand hygiene and personal protective equipment (gloves).

Please refer to A748.

3. Observations, interviews, and review of Hospital documents on 1/12/5, 1/13/15, and 1/14/15, indicated the Hospital failed to ensure the ICN maintained a system for identifying, reporting, investigating, and controlling infections of patients and personnel.

Please refer to A749

4. Observations, interviews, review of personnel files and review of Hospital policies, on 1/12/15, 1/13/15, and 1/14/15, indicated that the Chief Executive Officer (CEO) and the Director of Nursing (DON) failed to ensure that a Hospital-wide infection control (IC) training and monitoring program was implemented and maintained.

Please refer to A756.

Based on record review and interview, the facility failed to:

1. Ensure that the social work assessments for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community. (Refer to B108)

2. Develop and document comprehensive multidisciplinary treatment plans (MTPs) based on the individual needs of patients for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14). Specifically, the facility used preprinted treatment plan forms based on two (2) specific problems. The facility used the problems of "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal" for all six (6) patients regardless of variations in their diagnosis, problems and moods. Three (3) of six (6) active sample patients (A5, A13 and A14) did not have psychiatric interventions by physicians on the MTPs, causing those to not be interdisciplinary. Failure to individualize the treatment plans of patients can prevent staff from knowing how to address each patient's specific problem(s) which can result in unmet needs and potentially prolong lengths of hospitalization. (Refer to B118)

3. Develop Master Treatment plans (MTPs) that included long-term goals (LTG) and/or short-term goals (STG) that were stated in observable, measureable patient behaviors to be achieved for six (6) of six (6) active sample patients (A3, A4, 5, A11, A13, and A14). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient's behaviors. (Refer to B121)

4. Ensure that the Master Treatment Plan (MTP) interventions consistently addressed specific treatment needs for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13 and A14). The staff interventions in the MTPs were stated primarily as generic discipline functions. The facility used pre-printed treatment plans based on two (2) identifying psychiatric problems- "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal." The pre-printed interventions were the same or similar for each patient regardless of each patient's individual needs. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problem(s) and may result in prolonged hospitalization. (Refer to B122)

5. Provide active treatment, including alternative intervention for two (2) of six (6) active sample patients (A3 and A11) who were not motivated to consistently attend the groups offered on the unit. Rather than providing individualized treatment to meet the patients' needs, these patients were allowed to lie on their beds or wander around the unit during the hours when groups were held. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125)

Based on staff interview and review of Professional staff meeting minutes the facility failed to ensure an institutional plan and budget existed. Finding include:

During the entrance conference on 1/12/15 at 9:15 A.M. the Administrator/Director Nursing Services (DNS) was asked to provide the survey team with evidence of an institutional plan and budget which included an annual operating budget, all anticipated income and expenses, provided for capital expenditures for at least a 3-year period and identified in detail the objective of and the anticipated sources of financing for each anticipated capital expenditure regarding acquisition of land, improvement of land, buildings and equipment or replacement, modernization and expansion of buildings and equipment.

As of 1/13/15 at 12:30 P.M. the survey team did not receive any plan and budget for this hospital.

During interview on 1/13/15 at 1:00 P.M. the chief executive officer, (CEO)/owner was again asked for verification of an institutional plan and budget for this hospital. She was unable to produce any verification and said she needed to contact her accountant for this information.

Review of the Professional Staff meeting minutes for the year 2014 lacked any indication budgetary plans were discussed.

On 1/14/15 last day of survey, the CEO stated she was unable to provide any verification of an exiting budget.

Based on documentation review and staff interview, the Hospital failed to ensure prompt resolution of a grievance for 3 of 6 non-sampled patients (NS#A, NS#B and NS#C).

Findings include:

1. Review of the Hospital's policy on 01/13/15, regarding grievances/complaints stated the following:

Upon receipt of a complaint, or at any time the Person in Charge becomes aware of any condition or incident which he or she believes to be dangerous, illegal or inhumane, he or she shall: a) Undertake any necessary fact-finding; b) Give a written decision to the parties within ten days containing findings of fact and conclusions and any actions to be taken.

According to the hospital's policies, the Person in Charge of investigating and responding to grievances was the Human Rights Officer (HRO).

2. Patient NS#C alleged that during their stay at the Unit, during 03/2014, a physician was disrespectful, hostile and unpleasant toward him/her. No other information was available regarding the Hospital's investigation of the patient's grievance.

3. Patient NS#A had written a complaint on 07/18/14, indicating that on 07/15/14, a nurse at the Unit disrespected him/her. The complaint indicated that a nurse had falsely accused Patient NS#A of taking medications that the patient said he/she had never received. According to the statement written by the HRO, the HRO had met and spoken to the patient on 07/18/14, regarding the issue and that the patient wanted a follow-up as to what was going on with the complaint. There was no other information available regarding the Hospital's investigation.

4. Patient NS#B had written a complaint on 10/14/14, indicating that on 10/12/14, a Mental Health Assistant acted inappropriate with other male patients and had bothered Patient NS#B. According to a statement written by the
HRO, HRO went to see Patient NS#B, but NS#B was discharged. There was no other information available regarding the investigation.

5. On 01/14/15 at 7:45 A.M., during interview, the HRO said that she started the position within the past month and was not aware if the above complaints were thoroughly investigated. She also stated that she would have investigated the complaints further and would have notified the patients in writing of the findings, as per Hospital policy.

Based on observation and staff interview, the Hospital failed to maintain patients' rights for personal privacy for 2 patients (#24, #26), at the Inn Unit and 3 (#33, #34 and #35) restrained patients at the Hospital Unit in a total sample of 36 patients.

Findings include:

1. Observation on the Hospital Unit in the Crisis Room on 1/12/15 at 11:30 A.M., with RN (Registered Nurse) #2, revealed there was a bed in the center of this small room (12 feet by 9 feet), where a patient who is potentially harmful to him/herself or others is put in (4 point) physical restraints. RN #2 stated that a staff member sits in this room next to the patient who is in physical restraints in this bed.

The door of this Crisis Room has a large window (22 inches by 22 inches) which is located on the main patient hallway. There was no mechanism in place to protect the personal privacy of a patient in restraints from other patients walking by this room.

During an interview with RN #2, she said that there is no mechanism to maintain a patient's privacy from view by visitors, other patients and staff, when restrained.

Pleasee see A0166.



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2. Observations at 9:45 A.M. on 1/12/15, indicated that patients were assigned rooms on the first floor of the Inn Unit. The rooms were numbered 1 through 4. Room #1 had one bed, Room #2 had four beds, Room #3 had two beds, and Room #4 had two beds. Access to Room #3 was through Room #2.

Observations on 1/12/15 at 9:55 A.M., indicated that Patient #2 was assigned to Room #3 and Patient #24 was assigned to Room #2. The only access to Room #3 was through Room #2. Privacy for Patient #24 during his/her detox was limited, as Patient #2 could only access Room #3 through Room #2.

Patient #24, was observed in Room #2, on 1/12/15 at 9:55 A.M. with the shades drawn and the room darkened. During interview on 1/12/15 at 10:00 A.M., Registered Nurse (RN) #1 said that Patient #24 was detoxing (a process or period of time in which one abstains from or rids the body of toxic or unhealthy substances) from drugs and/or alcohol and needed a quiet and calm environment.

3. For Patient #26, observation at 11:30 A.M., on 1/14/15, indicated that Patient #26's privacy was not consistently maintained. Patient #26 was assigned to Room #3 and Patient #29 was assigned to Room #2.

Privacy for Patient #26 was limited during detox, as Patient #29 could only access Room #3 through Room #2, while Patient #26 was having withdrawal symptoms (shakiness, anxiety, nausea) while detoxing from drugs and alcohol.

For Patient #26, medical record review on 1/14/15, indicated the patient was admitted for drug and alcohol abuse and symptoms of withdrawal from drugs and alcohol. In an observed conversation with RN #7, at 9:45 A.M. on 1/14/15, Patient #26 said (s)he was shaky, anxious and had an upset stomach.

In an interview on 1/14/15 at 11:30 A.M., Patient #26 told the Surveyor that (s)he was "feeling real sick, not well at all."

4. Observations in the Nurses' Station on the Inn Unit at 10:00 A.M. on 1/12/15, revealed that the Certified Registered Nurse Practitioner (CRNP) directed Patients #1 and #2 to his interview room, through the Nurses' Station. The room the CRNP used to interview patients was located off a corridor in the back of the Nurses' Station. There was an entrance to this corridor through a door that did not require patients to go through the Nurses' Station. RN #1 told the CRNP to have the patients use the other entrance.

At the time of the observation, Registered Nurse (RN) #1 said that Hospital policy prohibited patients from entering the Nurses' Station because patients' medical records and other patient information was located there and this information could be potentially seen by patients.

Observations, in the Nurses' Station on the Inn Unit, at 9:05 A.M. on 1/14/15, indicated that Patients #21 and #28 started to enter the Nurses' Station. RN #7 had to remind the CRNP to direct his patients to the back door entrance to his interview room, not the entrance to the Nurses' Station.

Based on medical record review, observations and interviews, the Hospital failed to provide patient care in a safe setting as there was no system for patients to alert staff in the event of a need for assistance for 4 (#2, #24, #26, #27 ), of 36 Patients. Findings include:

1. Observations in the Inn Unit on 1/12/15 at 9:45 A.M., indicated:

a. The First Floor, that contained 9 beds, and the second floor contained 21 beds with the nursing station being on the second floor.

b. Review of the staffing sheets for 1/12/15, located in the Second Floor nurses' station, indicated that the Inn Unit was staffed with one Registered Nurse (RN), one Mental Health Assistant (MHA) and one Unit Secretary days and evenings. On the night shift the Inn Unit was staffed with one RN and one MHA.

c. On 1/12/15 there were 5 patients assigned to rooms on the first floor of the Inn Unit.

2. Patient #24 was assigned to a room, located on the First Floor of the Inn Unit. Observations in Room #2, on 1/12/15 at 9:45 A.M., indicated that the room was dark, window shades pulled down and Patient #24 was sleeping. There was no nurses call system observed in the room. Review of patient room assignments indicated that Patient #24 was alone in the room. There was no system by which the patient could access staff.
During interview on 1/12/15 at 1:50 P.M., RN #1 said the Second Floor Nurses' Station served all of the patients on both floors of the Inn Unit. Additionally, RN #1 acknowledged that there was no way other than calling out for help that a patient could alert staff in the event of an emergency.

RN #1 also said that Patient #24, on the First Floor, was detoxing from drug abuse.

4. For Patient #2, medical record review on 1/12/15, indicated that the History and Physical (H&P) examination identified that Patient #2 had a history of withdrawal seizures. Patient #2 was assigned to Room #2 on the First Floor. There was no nurse call system observed in Room #2 for Patient #2 to use in the event of an emergency.

5. For Patient #26, review of the admission H&P, dated 1/13/14, indicated that Patient #26 was suffering from mild withdrawal symptoms.

Patient #26 was assigned to a room, located on the First Floor of the Inn Unit. During interview at 11:30 A.M. on 1/14/15, Patient #26 said that (s)he didn't go to Group Meeting in the morning because (s)he didn't feel well and was real sick. When Patient #26 was asked by the Surveyor how (s)he would get help in an emergent or urgent situation, since (s)he was alone in the room, and on the First Floor, Patient #26 said, "I guess I would start yelling and calling for help since I have no pull cord (nurse call system) to use."

6. For Patient #27, review of the admission history and physical dated 1/6/15, indicated that Patient #27 had diagnoses that included anxiety, depression and history of suicide attempt.

Patient #27 was assigned to Room #3, on the First Floor of the Inn Unit. The First Floor of the Inn Unit lacked a call system for the patient to access assistance as needed.

Based on documentation review and staff interview, the Hospital failed to have a written policy and procedure to ensure that all patients were protected from abuse and neglect. In addition, the hospital failed to implement its policy of checking CORI [Criminal Offender Record Information] for 1 of 5 Physicians (Medical Director) and 1 of 2 Social Workers (Social Worker #1) personnel records reviewed.

The findings included:

1. On 01/13/15, review of the Hospital's policy and procedure dated 09/2014, for "Governing Investigations, Complaints and Incident Reporting, " indicated that the Hospital was to report, investigate and resolve all complaints." According to the policy and procedure, " all above the line complaints " (i.e., serious injuries to patients requiring medical treatment, patient to patient sexual or physical assaults), would be communicated to the Department of Mental Health Licensing Office.

On 1/12/15 at 1:45 P.M., on 1/13/15 at 4:00 P.M., and on 1/14/15 at 3:00 P.M., Surveyor #3 asked the Director of Nurses for the Hospital's Abuse Policy and Procedure. Interview with the Director of Nurses on 01/14/15 at 2:45 P.M., indicated the Hospital did not have a policy and procedure that specifically identified all forms of abuse (physical harm, injuries of unknown origin, pain, mental anguish) and neglect (staff neglect, harassment, and/or indifference to the infliction of injury or intimidation by staff towards patients.) The Director of Nurses acknowledged there was no policy or procedure, beyond that of patient complaints/grievances, that incorporated the key elements of abuse and neglect prevention (identifying abuse and neglect, screening, training, protection, investigation and reporting), as required.

2. Review of the Hospital's procedure for Hiring of Personnel indicated the following procedure must be followed: "Before making a commitment to a prospective employee, consultant, or volunteer to work, the CORI check will be conducted."

A. Review of the employee information for Social Worker #1 on 01/14/15, indicated a CORI check was not obtained prior to hire. Social Worker #1 was hired on 02/10/14. However, a CORI check was completed 07/3/14, 143 days after hire.

During an interview on 01/14/15 at 11:35 A.M., the Director of Human Resources said Social Worker #1's CORI check was not completed prior to hire, as per Hospital policy.



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3. Review of the personnel record of the Medical Director indicated that the CORI check was not completed prior to hire. The Medical Director was hired 02/27/12 and the CORI was done on 03/14/12 (15 days after the date of hire).

Based on record review, the Hospital failed to develop, review, and revise the care plans for 2 of 3 restrained patients (#33 and #34) in a total sample of 36 patients.

Findings included:

1. For Patient #34, the hospital failed to update the care plan to include the use of restraints.

Review of Patient #34's clinical record on 01/13/15, indicated the patient was admitted to the hospital during 02/2014, with diagnoses including alcohol dependence and bipolar disorder.

Further record review indicated the patient had a Nursing and Treatment Plan dated 02/18/14. On 02/20/14 at 8:50 P.M. until 10:00 P.M. (an hour and 10 minutes), Patient #33 was restrained in four point restraints. According to record review, the patient was assessed for the use of restraints and the patient had requested the restraints because he/she was afraid that he/she would harm another patient or themselves.

Further record review indicated that neither the Nursing Care Plan or the Treatment Plan were updated to include the use of restraints.

2. Patient #33, the Hospital failed to update the care plan to include the use of restraints.

Review of Patient #33's clinical record on 01/13/15, indicated the patient was admitted to the hospital during 04/2014, with diagnoses including alcohol dependence and mood disorder.

Further record review indicated the patient had a Nursing and Treatment Plan dated 04/16/14. On 04/17/14 at 7:50 P.M., Patient #33 was restrained in a physical hold for 10 seconds in order to prevent the patient from hitting another patient.

Further record review indicated that neither the Nursing Care Plan or the Treatment Plan were updated to include the use of restraints.

Based on observations, interviews, review of Hospital documents, and review of Quality Assessment Performance Improvement (QAPI) and Infection Control Committee minutes, the Hospital failed to ensure that the Program measured, analyzed, and tracked quality indicators of care and operations of the Hospital. Findings include:

1. Interview with the Hospital Facilities Director on 1/13/15 at 9:00 A.M., and 1:00 P.M., indicated that he was responsible for oversight of Housekeeping, Maintenance and Dietary Services. The Hospital Facilities Director said that had not developed and implemented performance improvement indicators to monitor, track, trend and analyze quality indicators for the contracted services of medical waste removal and laundry services.

Observations of the Inn Building Housekeeping Closet on 1/12/15 at 10:30 A.M., and the Occupational Therapy Building on 1/13/15 at 1:30 P.M., indicated that the areas were dirty with debris and layers of dust.

Additionally, the Hospital Facilities Director said that he was supposed to conduct an environmental audit using the Hospital Environmental/Physical Facilities Annual/Quarterly Audit Tool. The Hospital Facilities Director said that he had not conducted any audits using the tool.

Please also refer to A748 and A749.

2. Interview with the Infection Control Nurse (ICN) on 1/13/14 at 10:45 A.M., indicated that she only monitored, tracked and trended infection control practices (e.g., hand hygiene, proper use of personal protective equipment), for Department of Nursing staff.

Observations on 1/12/15 at 10:00 A.M., and 1/14/15 at 8:00 A.M. and 1:30 P.M., in the Inn Building, indicated that Nurses and Mental Health Assistants (MHA) failed to adhere to Infection Control Standards of Practice for Hand Hygiene.

Please also refer to A748 and A749.

3. During interview on 1/13/14 at 10:45 A.M., The ICN also said that MHAs were responsible to disinfect the patient washing machines, twice weekly and a disinfection log, placed at the washing machine, was to be completed with each disinfection. The logs were to be used as an indicator that the disinfections occurred. The Surveyor then requested, on 1/13/15 at 11:15 A.M., to see the washing machine disinfection logs for 10/1/14 to 1/13/15. The logs were not provided by the time of the Exit Conference at 3:45 P.M. on 1/14/15.

A note from the Administrative Assistant on 1/14/15 at approximately 3:00 P.M., indicated that there was no washing machine disinfection log maintained.

Please also refer to A748 and A749.

Based on staff interview, review of Hospital documents, and review of Quality Assessment Performance Improvement (QAPI) and Infection Control Committee minutes, the Hospital failed to take action on identified opportunities for improvement. Finding include:

1. Review of the Infection Prevention and Control Plan 2014 identified the Influenza outbreak 2014-2015 season as a risk. The goal was to decrease risk of influenza outbreak by increasing influenza vaccination rate of staff to above 50% for this year and to develop vaccination process for patients with a time frame of October 2014.

During interview on 1/14/15 at 1:30 P.M., the Administrator said that currently the hospital does not offer the influenza vaccine to patients and will not be doing anything more with the patients to decrease their risk of influenza outbreak at this time. They did not develop a vaccination process for patients as planned.

In addition, although some education was done with staff regarding the benefits for staff to be vaccinated against the influenza, they had no formal plan with time frames to determine how effective the education was in increasing staff vaccination rates. The Administrator said once the flu season is over in March 2015 is when they will collect the data to see if 50% of the staff were vaccinated.

2. Review of the key performance measures based on important aspects of care identified effective August 2014 identified that 15 charts will be audited monthly to determine how many groups were offered each week and patient compliance rate of attendance at groups. Review of the September-December 2014 key performance measures based on important aspects of care identified minutes does not address this issue.

During interview on 1/14/15 at 1:45 P.M. the Administrator said that not all of the identified opportunities have been addressed because the Hospital is in transition and staff are still learning their roles.

Based on staff interview, review of Hospital documents, and review of Quality Assessment Performance Improvement (QAPI), the hospital has not conducted any performance improvement projects. Findings include:

Review of PI/QA committee meeting minutes and the key performance measures based on important aspects of care identified from May 2014 - Dec 2014 indicated no performance improvement projects being conducted.

Review of the Quality Management Program policy does not address conducting any performance improvement projects.

During interview on 1/14/15 at 1:30 P.M. the Administrator said there has been no performance improvement projects in the past 6 months and none planned for the future.

Based on staff interview, review of Hospital documents, and review of Quality Assessment Performance Improvement (QAPI), the governing body failed to ensure a hospital-wide quality assessment and performance improvement program is clearly defined, implemented and maintained. Finding include:

On 1/14/15, review of the Hospital's Quality Management Program policy indicated the committee members included representatives of the Medical staff, Administration, Nursing Services, Nutrition, Environmental Services, Social Work, Psychology and Therapeutic Activities. The policy lacked any reference for the hospital to conduct performance improvement projects as required.

During interview on 1/13/15 at 1:00 P.M. the Chief Executive Office CEO/owner stated she does not attend the the QAPI meeting. Issues are brought to her attention through the Professional Staff Meetings and referred the surveyor to those meeting minutes.

Review of the Professional staff meetings from 5/2014-10/2014 indicated the following:
The 5/28/14 meeting indicated there was a QAPI meeting on 5/27/15 but no committee report for this meeting.
The 6/26/14 meeting indicated no report from QAPI committee.
The 7/24/14 meeting indicated a QAPI meeting will be held next Tuesday; no committee report was submitted.
The 9/11/14 meeting indicated a QAPI meeting will be held 9/23; no committee report was submitted.
The 10/23/14 meeting indicated the committee report for QAPI was blank.

Review of the QAPI committee meeting minutes from July 2014-current indicated there were meetings every month except November and there was no medical staff representation at any of the meetings.

During interview on 1/14/15 at 1:30 P.M. the Adminstrator stated the Medical Director is required to attend these meeting but has not been there as required. She also stated there has been no performance improvement projects in the year that she was aware of and none planned for the future. She also said she attends the Professional Staff meetings and if there were concerns from the QAPI committee, she would discuss with the CEO.

Based on review of the credential files and staff interview, the Hospital failed to re-evaluate the competency of an on call Physician who was not a Psychiatrist, nor trained in the diagnosis and treatment of psychiatric patients, for 1 of 5 Physicians (Physician #2). Findings include:

1. Review of the credential file for Physician #2 on 1/13/15 at 9:00 A.M., indicated Physician #2's date of hire was 5/27/13. Physician #2's experience and education was in plastic surgery.

Review of a reference questionnaire from this Hospital prior to hire read, "To provide relevant information for the clinician's competence." It does not specify competence in what. The response read, "Excellent plastic surgeon."

Review of the Competency Evaluation and Training Needs Assessment of 5/27/13, read, "Are there any areas or skills that need additional or upgrading of training..." The area for response Yes or No was left blank (not answered). Written below this question, the Medical Director wrote, "CMEs (Continuing Medical Education) in Psychiatry, assistance with admission and help with documentation." There was no evidence in the credential file that the aforementioned competency needs were ever addressed.

Review of Physician #2's letter for privileges on 5/27/13, indicated he was granted full privileges.

During an interview with the Director of Human Resources on 1/13/15 at 9:00 A.M., there was no evidence that additional education, experience or assistance with Psychiatric admissions had been conducted. When asked for Physician #2's position description, the Director of Human Resources said, "There was no job description for him. The only physician job description we have is for a staff psychiatrist, which he is not."

During an interview with the Medical Director on 1/13/15, he indicated that there is no documented evidence that Physician #2 had received additional assistance/help with psychiatric admissions or documentation. The evaluation mechanism used is informal feedback from the nurses.

Based on review of meeting minutes and administrative staff interview, the medical staff is not well organized and accountable to the governing body for the quality of the medical care provided to the patients. Findings include:

According to the Hospital's Professional Staff Bylaws, dated 1/2014, page 44, it read, "Professional Staff shall be organized into departments, one of the departments is Psychiatry." On page 57 under Section 3, it read, "Departments, Section, Services and Committee Meetings will have regular meetings. Departments, sections, services and committees shall hold a minimum of four meetings per year."

Review of the meeting minutes indicated there were no Medical Staff minutes.

Review of the Profession Staff Meetings for the past 9 months (January 22, 2014 to September 11, 2014), indicated that the Medical Director attended only 3 of the 9 meetings. In the minutes, it is documented that he has clinical issues with his schedule related to attending the meetings.

During a interview with the Director of Human Resources on 1/14/15 at 11:30 A.M., she was asked, "What is the purpose of the Profession Staff Meetings?" She said, "They are the Senior Management meetings for clinical and nonclinical, for cross informational department updates and process changes."

During an interview with The Medical Director on 1/12/15 at 2:30 P.M., he said that there was no documentation of meetings of the Medical Director with the medical staff; the Physicians and Nurse Practitioner.

Although the Medical Director stated that he has regular ongoing communication with the Nurse Practitioner and the physicians covering off tour and on weekends, it was not formally organized.

Based on review of credential files and interview, the Hospital failed to ensure that practitioner's privileges were related to their appointment for 2 of 5 practitioners (Physician #2 and Certified Registered Nurse Practitioner (CRNP) #1). In addition, the clinical privileges were not signed by the Certified Registered Nurse Practitioner and the Nursing Administrator. Findings include:

1. Review of credential files on 1/13/15, indicated that the privileges of Physician #2, did not include privileges in Psychopharmacology (ordering psychiatric medications) or detoxification protocols for substance abuse. This Physician's privileges were in General Medicine, admitting privileges history and physical examinations, and access to medical records and orders.

Review of Patient #4's medical record on 1/14/15, indicated Physician #2 admitted and wrote orders for the alcohol/benzodiazepine protocol for this patient, who was admitted with substance dependence, anxiety and depression

During an interview with the Medical Director on 1/12/15 at 2:30 P.M., he indicated that the on call physicians ordered medications for the substance abuse protocols, and antipsychotic medications for detoxification and dual psychiatric diagnoses.

During an interview with the Coordinator of Credentialing on 1/13/15 at 9:15 A.M., she indicated that Physician #2's delineation of privileges lacked authorization (via privileges) to order psychiatric medications and detoxification protocols, even though he ordered these medications.

2. For CRNP #1, the hospital failed to ensure that: the scope of practice and delineation of privileges for 1 of 1 advanced practice nurse, reflected his practice related to the diagnosis of patients and involvement in the detoxification protocols. In addition, the CRNP's privileges were were undated and were not signed by the CRNP or the Director of Nursing as follows:

CRNP #1 was employed primarily at the Inn, which treated patients for substance abuse detoxification and dual psychiatric diagnoses. CRNP #1 diagnosed and treated patients for detoxification from substance abuse and stable psychiatric disease. In addition, review of the credential file of CRNP #1, on 1/13/15, indicated that the scope of practice and delineation of privileges for the Nurse Practitioner lacked the following:

(1) The CRNP's delineation of privileges did not include diagnosis of patients and his involvement with the detoxification protocols for substance abuse on the Detoxification Units.

(3) The CRNP's delineation of privileges were undated and were not signed by the CRNP or the Director of Nursing.

During an interview with CRNP #1 on 1/14/15 at 10:00 A.M., he said that there is no formal regular meetings with the Medical Director (Supervisor oversight) or the Administrator (also the Director of Nursing). The discussions he has with the Medical Director are usually limited to telephone discussions with no real time evaluation of patients (at the Inn) together for diagnosis and treatment.

Based on review of the credential file and staff interview for 1 of 5 practitioners (Physician #2), the Hospital failed to adhere to the qualifications for the continuation of hospital privileges. Findings include:

According to the Hospital's Professional Staff Bylaws, dated 1/2014, on page 5 it read, "To attain a high level of professional performance of all practitioners authorized to practice in the Hospital through the appropriate delineation of the Clinical Privileges that each may exercise in the Hospital and through an ongoing review and evaluation of their performance." On page 6, it read, "Clinical Performance, Current experience, clinical results and utilization practice pattern, documenting ability to provide patient care services at an acceptable level of quality..."

Review of Physician #2 credential file on 1/13/15 at 9:00 A.M., indicated Physician #2's date of hire was 5/27/13. Physician #2's experience and education was in plastic surgery.

Physician #2's Professional Staff Reviews (his performance evaluations) completed by the Medical Director were as follows:

- On 7/22/13, unsatisfactory performance (in 1 of 4 categories) for patient admission evaluation and he needs help with diagnoses and DSM (the classification found in Diagnostic and Statistical Manual of Mental Disorders). The other 3 categories were satisfactory.

- On 11/13/13, all 4 performance categories were satisfactory.

- On 2/10/14, unsatisfactory performance (in 1 of 4 categories) in availability and responsiveness to nursing staff and unsatisfactory for timely arrival on duty and completion of records. Under comments; problems not showing up on time.

- On 4/14/14, satisfactory for all 4 performance categories. Under comments inconsistent performance.

- In the 3rd quarter of 2014 (undated), unsatisfactory in all 4 categories of performance. Under comments it read that the Medical Director discussed this evaluation with Physician #2, administration and the clinical staff. It was recommended by the Medical Director not to continue Physician #2's clinical privileges.

Review of the on call work schedule for May 2014, June 2014 and July 2014 indicated Physician #2 continued to be on call for the Hospital (despite the Medical Director recommending discontinuation of clinical privileges).

Review of the Physician's credential file with the Director of Human Resources on 1/14/15 at 9:30 A.M., indicated that Physician #2's privileges were continued without interruption and there was no corrective plan for the unsatisfactory performance.

Based on record review and staff interview, the hospital failed to ensure that the medical bylaws included the requirement for the completion of a medical history and physical examination for each patient no more than 30 days before or 24 hours after admission or registration. Findings include:

Review of the Professional Staff Bylaws, dated 1/2014, indicated that there was no criteria for the completion of the history and physical examinations.

During an interview with the Administrator on 1/14/15 at 8:15 A.M., she said, "If the criteria for the history and physical is not there, then it's not there."

Based on record review and staff interview, the hospital failed to develop, review, revise and/or implement the care plans for 6 sampled Patients (#2, #4, #26, #27, #33, #34) and in a total sample of 36 Patients.

Findings included:

1. Patient #2 had diagnoses that included alcohol dependence, depression, anxiety, and history of withdrawal seizures. Medical record review indicated that Hospital staff failed to identify Patient #2's history of withdrawal seizures as a problem and also failed to develop and implement a plan of care for withdrawal seizures.

2. For Patient #26, review of the admission history and physical dated 1/13/14, indicated that Patient #26 had a history of alcohol dependence, and crack cocaine and marijuana abuse and was suffering from mild withdrawal symptoms.

Review of the Nursing Care Plan, initiated by Certified Registered Nurse Practitioner (CRNP) #1, indicated that only the problems of anxiety and alcohol dependence were identified. CRNP #1 failed to develop a care plan for Patient #26's withdrawal symptoms.

3. For Patient #27, review of the admission history and physical dated 1/6/15, indicated that Patient #27 had diagnoses that included polysubstance abuse (alcohol, cocaine, and marijuana), anxiety, depression and history of suicide attempt. Review of the Nursing Care Plan indicated that it lacked a plan to monitor the patient for thoughts of suicide.



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4. For Patient #4, the Hospital failed to implement the medical plan of care which indicated that the patient's vital signs be obtained four times a day daily for three days.

Record review on 01/12/15, indicated the patient had a physician's order, dated 1/5/15, which read vital signs four times daily for three days and then two times daily for three days. According to the 1/2015 Medication Record Administration (MAR), vital signs were not obtained on 1/6/15 at 1:00 P.M., and on 1/8/15 at bedtime, per the medical plan of care.

On 1/12/15 at 10:45 A.M., Registered Nurse #2 said there was no documentation to indicate the vital signs were obtained on 1/6/15 and 1/8/15, as per the plan of care.

5. For Patient #34, the Hospital failed to update the care plan to address the use of restraints.

Review of Patient #34's clinical record on 01/13/15, indicated the patient was admitted to the hospital during 2/2014, with diagnoses including alcohol dependence and bipolar disorder.

Further record review indicated the patient had a Nursing and Treatment Plan dated 2/18/14. On 2/20/14 at 8:50 P.M. until 10:00 P.M. (one hour and 10 minutes), Patient #33 was restrained in four point restraints. According to record review, the patient was assessed for the use of restraints and the patient had requested the restraints because he/she was afraid that he/she would harm another patient or themselves.

Further record review indicated that neither the Nursing Care Plan or the Treatment Plan were updated to address the use of restraints.

6. Patient #33, the Hospital failed to update the care plan to address the use of restraints.

Review of Patient #33's clinical record on 1/13/15, indicated the patient was admitted to the hospital during 4/2014, with diagnoses including alcohol dependence and mood disorder.

Further record review indicated the patient had a Nursing and Treatment Plan dated 4/16/14. On 4/17/14 at 7:50 P.M., Patient #33 was restrained in a physical hold for 10 seconds in order to prevent the patient from hitting another patient.

Further record review indicated that neither the Nursing Care Plan or the Treatment Plan were updated to address the use of restraints.

Based on record review, observation, and interview, the Hospital failed to administer 2 medications within an hour of their scheduled time, failed to administer medication according to a physician's order, and failed to complete an evaluation of the effect of PRN (as needed) medications the pain assessment for 14 patients (#2, #5, #6, #7, #9, #11, #12, #13, #15, #18, #26, #27, #29, and #30) out of 36 patients.

Findings include:

1. For Patient #5, the Hospital failed to administer 2 medications within an hour of their scheduled time.

According to the Hospital's policy's titled, Medications are accurately and safely administered, undated, it read, "Medication labels are verified four times using the five "rights" of medication administration (right patient, drug, dose, route, and time)...

Patient #5 was admitted during 1/2015,with the pertinent diagnoses of Depression and substance abuse.

During a medication pass on 1/13/15 at 11:50 A.M. with the Surveyor, Registered Nurse (RN) #5 stated she was passing 9:00 A.M. medications. She administered Lamictal 100 milligrams (mg) by mouth and Topamax 100 mg by mouth at 9:00 A.M. (both used as mood stabilizer medications).

Review of the medication administration sheet indicated these medications were scheduled to be administered at 9:00 A.M. The Surveyor asked why are you administering these medications at the wrong time, 2 hours and 50 minutes late? RN #5 stated, "We do not have these medications in stock and have to wait for the Inpatient Pharmacy. This happens a few times a week, where meds (medications) are given 2 to 3 hours late especially on Mondays."

During an interview with RN #2 on 1/13/15 at 2:30 P.M., she said they have a 1 hour time frame when the medications are scheduled to be given, to administer the medication to the patient.

2. The Hospital failed to complete the Pain Assessment sheet documenting the pain scale (severity of pain) number before and 30 minutes after treatment with pain medication (a method for determining the effectiveness of the pain medication).

According to the Hospital's Pain Management Policy, dated February 2011, it read, "In order to ensure that pain control is monitored and effective, the following procedure should occur: The Pain Scale Form will be maintained within the Medication Administration Record. The Medication Nurse will be responsible for recording an entry on the Pain Scale form when dispensing pain medication and or treatment for pain."

A. Patient #11 was admitted to the Hospital during 01/2015, with polysubstance dependency and headaches. For this Patient's headaches, Motrin 600 mg by mouth was given on 1/7/15 at 10:30 A.M. and Excedrin two tablets on 1/11/15 at 1:15 P.M. and on 1/12/15 at 6:30 A.M. The assessment for the severity of this patient's pain on the Pain Scale Form was left blank before and after Motrin and Excedrin were given.

B. Patient #12 was admitted to the Hospital during 1/2015, with depression, suicidal ideation, a recent overdose of heroin and headaches. For this patient's headache, Motrin 600 mg was given on 1/11/15 at 1:45 P.M. The assessment for the severity of this patient's pain on the Pain Scale Form was left blank before and after Motrin was given.

C. Patient #13 was admitted to the Hospital during 1/2015, with Opiate abuse and headaches. For this patient's headache, Motrin 600 mg was given on 1/11/15 at 1:45 P.M.. The assessment for the severity of this patient's pain on the Pain Scale Form was left blank before and after Motrin was given.

D. Patient #15 was admitted to the Hospital during 1/2015, with Anxiety, Depression, Opiate dependency and back pain. For this patient's back pain, Motrin 600 mg was given on 1/11/14 at 4:00 P.M. and on 1/12/15 at 7:00 A.M. The assessment for the severity of this patient's pain on the Pain Scale Form was left blank before and after Motrin was given.

During an interview with RN #2 on 1/13/15 at 2:30 P.M., she said that the the area for rating pain severity on the Pain Scale Form should be filled in the for severity of pain before and 30 minutes after the giving the pain medication.


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3. For Patient #9, the facility failed to complete the pain Assessment sheet documenting the pain scale number 30 minutes post treatment for 3 days when PRN [as needed] Tylenol was provided.

Patient #9 was admitted in 01/2015, with diagnoses including arthritis and knee pain.

On 01/10/15, 01/11/15 and 01/12/15, the patient received PRN doses of Tylenol for either knee pain or a headache. On all 3 days, the facility failed to evaluate the effectiveness of the medication 30 minutes after the administration of the medication as required on the pain assessment sheet.

4. For Patient #30, the facility failed to complete the pain Assessment sheet documenting the pain scale number 30 minutes post treatment for 3 days when PRN [as needed] Baclofen was provided.

Patient #30 was admitted to the facility in 01/2015.

On 01/8/15, 01/11/15, and 01/12/15 the patient received PRN doses of Baclofen for back pain. On all 3 days, the facility failed to evaluate the effectiveness of the medication 30 minutes after the administration of the medication as required on the pain assessment sheet.


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5. For Patient #6, the Hospital failed to complete the Pain Assessment sheet documenting the pain scale number 30 minutes post treatment for 7 days when PRN (as needed) Motrin was provided, as per Hospital policy.

Review of the patient's clinical record on 01/13/15, indicated that Patient #6 was admitted in 01/2015, with diagnoses including, alcohol abuse, chronic back pain and depression. The patient had a physician's order dated 01/6/15, for Motrin 800 milligrams (mg) by mouth three times a day PRN, for back pain.

On 01/6/15, 01/7/15, 01/9/15, 01/10/15, 01/11/15, 01/12/15, and 01/13/15, the patient received PRN doses of Motrin for back pain. For the 7 days, the facility failed to evaluate the effectiveness of the medication 30 minutes after the administration of the medication, as required on the Pain Assessment form.

During an interview with RN #2 on 01/13/15 at 2:30 P.M., she said that the the area for rating pain severity on the Pain Scale Form should be filled in the for severity of pain before and 30 minutes after the giving the pain medication.

6. For Patient #7, the Hospital failed to complete the Pain Assessment sheet documenting the pain scale number 30 minutes post treatment for 4 days when PRN Motrin was provided, as per Hospital policy.

Review of the patient's clinical record on 01/13/15, indicated that Patient #7 was admitted in 01/2015, with diagnoses including, alcohol abuse, back pain and depression. The patient had a current physician's order for Motrin 800 milligrams (mg) by mouth three times a day PRN, for back pain.

On 01/10/15, 01/11/15, 01/12/15, and 01/13/15, the patient received PRN doses of Motrin for back pain. For the 4 days, the facility failed to evaluate the effectiveness of the medication 30 minutes after the administration of the medication, as required on the Pain Assessment form.

During an interview with RN #2 on 01/13/15 at 2:30 P.M., she said that the the area for rating pain severity on the Pain Scale Form should be filled in the for severity of pain before and 30 minutes after the giving the pain medication.


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7. Review of the Alcohol/Benzodiazepine Detox Protocol on 1/12/15, indicated that the medication Clonidine (for high blood pressure), 0.1 milligram (mg) was to be administered po (by mouth), every 4 hours prn (as needed), for 5 days, for blood pressures (BP) greater than 150/100.

For Patient #2, review of a Physician's Order written on 1/9/15, indicated to "change the parameters for administering Clonidine to BPs greater than 100/60 and a pulse greater than 60 (beats per minute), po, every 4 hours prn, for anxiety."

This order was then crossed out and the following order written on 1/9/15:
"Change parameters for Clonidine order to BP greater than 100/60 and a pulse greater than 60."

Review of BP readings were as follows:
On 1/9/15 at 6:00 P.M., Patient #2's BP was 127/84. No Clonidine was administered as ordered.
On 1/9/15 at 9:00 P.M., Patient #2's BP was 109/72. No Clonidine was administered as ordered.
On 1/10/15 at 7:00 A.M., Patient #2's BP was 116/76. No Clonidine was administered as ordered.
On 1/10/15 at 1:00 P.M., Patient #2's BP was 118/79. No Clonidine was administered as ordered.
On 1/10/15 at 6:00 P.M., Patient #2's BP was 125/77. No Clonidine was administered as ordered.
On 1/10/15 at 9:00 P.M., Patient #2's BP was 133/82. No Clonidine was administered as ordered.
On 1/11/15 at 7:00 A.M., Patient #2's BP was 114/67. No Clonidine was administered as ordered.
On 1/11/15 at 1:00 P.M. and 6:00 P.M., no blood pressures were documented as done in order to assess Patient #2 for the need to receive Clonidine, although required by the 1/9/15 physician's order to administer Clonidine every 4 hours, prn for BP greater than 100/60.

During interview on 1/12/15 at 1:50 P.M., RN #1 said that she heard in report (on 1/9/15) that the physician was lowering the Clonidine parameters so Patient #2 could get Clonidine for anxiety. RN #1 said she didn't know why the Clonidine for anxiety order was crossed out. Pateint #2 was supposed to get Clonidine for anxiety as well as high BP. RN #1 said that was a medication transcription error.

Review of Patient #2's medication administration record (MAR) on 1/12/15, indicated that on 1/10/15 it was documented on the MAR to "Hold Clonidine for BPs less than 100/60 and a pulse less than 60 (beats per minute)." Review of Physicians' Orders indicated there was no physician's order written on 1/10/15 for the above instructions.

Review of Patient #2's Detox Protocol and Physicians' Orders, revealed that the Patient had orders for Librium (sedative) 25 mg, every 4 hours PRN for withdrawal symptoms and for Mylanta 30 milliliters (ml) PRN, for upset stomach (dyspepsia).

Review of Patient #2's Nurses PRN Notes/Pain Assessment revealed the following:

-On 1/9/15 at 6:00 P.M., Patient #2 was administered Librium 25 mg for withdrawal symptoms. Patient #2 was not reassessed for the effect of the Librium one hour after administration.

-On 1/9/15 at 6:00 P.M., Patient #2 was administered Mylanta 30 ml for dyspepsia. Patient #2 was not reassessed for the effect of the Mylanta one hour after administration.

During interview on 1/12/15 at 1:50 P.M., RN #1 said patients were to be reassessed for the effect of PRN medications in one/half hour for pain medications and in one hour for other medications. Patient #2 was not reassessed for the effect of the medications, as required.

8. For Patient #26, review of the Nurses PRN Notes/Pain Assessment form indicated the following:

Patient #26 had a physician's order for Librium 50 mgs by mouth, every three hours, PRN for signs and symptoms of withdrawal; Immodium 2 mg po, PRN, for diarrhea; and Zofran 4 mg by mouth, for nausea.

On 1/13/15 at 12:45 P.M., Patient #26 was administered Librium 50 mg, by mouth for withdrawal symptoms. Patient #26 was not reassessed for the effect of the Librium one hour after administration, as required.

On 1/13/15 at 4:50 P.M., Patient #26 was administered Immodium 2 mg, by mouth for diarrhea. Patient #26 was not reassessed for the effect of the Immodium one hour after administration, as required.

On 1/13/15 at 4:50 P.M., Patient #26 was administered Zofran 4 mg, by mouth for nausea. Review of the MAR indicated Patient #26 was not reassessed for the effect of the Zofran one hour after administration, as required.

9. For Patient #27, review of the Nurses PRN Notes/Pain Assessment Form indicated the following:

On 1/6/15 at 8:00 P.M., Patient #27 was administered Librium 50 mg, by mouth for signs and symptoms of withdrawal. Patient #27 was not reassessed for the effect of the Librium one hour after administration, as required.

On 1/7/15 at 11:00 P.M., Patient #27 was administered Seroquel (a sleep aid) 50 mg. The route and reason for administering the Seroquel were not documented. Also, Patient #27 was not reassessed for the effect of the Seroquel one hour after administration, as required.

10. For Patient #29, review of the Nurses PRN Notes/Pain Assessment Form revealed the following:

On 1/13/15 at 6:55 P.M., Patient #29 was administered Librium 50 mg, PRN, by mouth for signs and symptoms of withdrawal. Review of the MAR indicated Patient #29 was not reassessed for the effect of the Librium one hour after administration, as required.

On 1/13/15 at 6:55 P.M., Patient #29 was administered Clonidine 0.1 mg, PRN, by mouth for a BP greater than 150/100. Patient #29's BP was 167/91. Patient #29 was not reassessed for the effect of the Clonidine one hour after administration, as required.

On 1/14/15 at 7:35 A.M., Patient #29 was administered Librium 50 mg, PRN, by mouth for signs and symptoms of withdrawal. Patient #29 was not reassessed for the effect of the Librium one hour after administration, as required.

During interview on 1/14/15 at 8:00 A.M., RN #7 said that patients were to be reassessed for the effect of PRN medications one hour after administration.


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11. For Patient # 18, clinical record review indicated patient #18 did not receive Clonidine per physician's order.

Patient #18 had a physician's order dated 1/7/15 to start the alcohol detox protocol with Librium day one on 1/7/15 at 6:00 P.M. This protocol included to give Clonidine 0.1 mg by mouth (po) every four hours as needed (prn) for a blood pressure >150/100.

Review of this patient's medication administration record indicated on 1/9/15 Patient #18 received Clonidine 0.1 mg po at 6:00 P.M.

During interview on 1/12/15 at 2:55 P.M., RN #1 stated this patient should not have received the Clonidine on 1/9/15 because the patient's blood pressure was below the required parameter.

Based on observation of the medication refrigerator indicated the Hospital failed to ensure that outdated biologicals (glucometer test strips) were not available for patient use. Findings include:

According to the manufacturer's guidelines for the glucometer control solution, it read, "Test strips as a quality control check to verify the accuracy of blood glucose test results." Under storage and handling, it read, "Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label ('Date Opened') as a reminder to dispose of the opened solution after 90 days."

Observation and interview with RN #3 on 1/12/15 at 11:50 A.M., indicated that there is not a process for ensuring that blood glucose strips are accurate. RN #3 showed the Surveyor the undated vial of control solution. RN #3 was not aware that the control solution needed to have a beyond use date on it.

Based on record review and staff interview the facility failed to provide emergency laboratory services when the nurse practitioner ordered a STAT [A common medical abbreviation for urgent or rush. From the Latin word statum, meaning immediately.] laboratory test for 1 patient [#30] in a sample of 36 patients.

Patient #30 was admitted to the facility in 1/2015 with diagnoses including major depression and stage #3 kidney disease.

On 1/13/15 at 12:00 P.M., the nurse practitioner ordered Patient #30 receive a STAT CMP [comprehensive metabolic panel] blood test.

On 1/14/15 at 1:30 P.M., the Unit Secretary for the Inn Unit said that the phlebotomist came to the facility that morning at about 10:00 A.M. to draw the blood. He said that he had let the phlebotomist in the door and she drew the blood for the test that the Nurse Practitioner had ordered the previous day.

The facility failed to ensure that the blood was drawn immediately or in a rushed manner. Instead, the blood was drawn over 24 hours after the order was written.

Based on observation and staff interview, the facility failed to ensure that the facility established policies and procedures to maintain a disaster menu and emergency food supplies in case of an emergency.

During interview on 1/12/15 at 10:30 A.M., the Food Manager said that the disaster food program was in the process of being developed. Additionally, the food manager said that there was no emergency food in the facility at that point.

During tour on 1/12/15 at 10:30 A.M. of the food service area it was observed that there was no food available in case of an emergency.

Based record review and staff interview the facility failed to ensure that the approved therapeutic diet manual was not more that 5 years old.

During observation of the kitchen on 1/12/15 at 10:30 A.M. it was observed that the facility was using the New England Diet Manual for Extended Care Facilities. The diet manual was dated 2008.

Interview with the Food Manager confirmed that the diet manual was more that 5 years old.

Based on staff interview and review of Utilization Review (UR) meeting minutes, the facility failed to have the appropriate composition of committee members. Findings include:

During interview on 1/14/15 at 1:30 P.M. the chairperson of the UR committee, who is a registered nurse, stated that there were no committee members who are doctors of medicine or osteopathy. The committee consists of herself as the Coordinator, the Administrator, the Admissions Office, the Director of Social Work and the Recorder.

Review of the UR committee meeting minutes from 1/1/14 - 1/1/15 lacked any member who was a doctor of medicine or osteopathy.

Based on observations, review of Hospital documents and interviews, the Hospital failed to develop, implement, and maintain procedures for the routine storage and disposal of trash. Findings include:

According to 42 CFR 482.41(b)(6), the term trash refers to common garbage as well as biohazardous waste. The storage and disposal of trash must be in accordance with Federal, State and local laws and regulations (i.e., EPA, OSHA, CDC, State environmental, health and safety regulations).

The Hospital Facilities Director said he did not receive any orientation and training for the proper handling and storage of biohazardous waste, proper labeling of the trash boxes, or maintenance of the tracking forms. The Hospital Facilities Director did not ensure that the Hospital's biohazardous waste was maintained and handled in accordance with proper procedures including the State Sanitary Code as follows:

1. During interview on 1/13/15 at 9:00 A.M., the Hospital Facilities Director said that the Hospital used a contracted company for the removal of biohazardous waste. During the interview, Surveyor #1 requested copies of the yellow waste tracking forms with the white forms for 1/2014 to 12/2014. The Hospital Facilities Director said that he did not have any white or yellow tracking forms. He also said that he never saw any such forms and was never informed of the need to maintain and track the forms, (called manifests). The Facilities Director said he was new to the position as of 9/2014.

2. During interview at 1:00 P.M., on 1/13/15, the Hospital Facilities Director said he found some yellow copies of tracking forms after he searched his office. The yellow copies of tracking forms were dated 8/4/14, 9/4/14, 9/29/14, 11/24/14, and 12/23/14. The Hospital Facilities Director said he could not find any other yellow forms. He also said he did not have any corresponding white forms that were returned to the Hospital by the biohazardous waste removal company, within 30 days after removal of the waste, as required by State Sanitation Code Regulations.

3. Observations of the biohazardous waste storage area on 1/13/15 at 1:45 P.M., indicated the biohazardous waste was not stored in a designated, locked space and lacked prominent signage to indicate the space was used for the storage of regulated, biohazardous waste, as required by State Sanitary Code Regulation. Observations also indicated that the biohazardous waste was stored in a corner of a large, open, extended area, identified by the Facilities Director as the Maintenance Department.

Observations also revealed one biohazardous waste transportation box that contained two red bags with medical trash, and two red needle boxes that contained used needles and syringes. The box lacked a label that identified the name and address of the waste generator (Hospital) and the waste transporter.

Interview with the Hospital Facilities Director at 1:50 P.M. on 1/13/15, indicated that he did not have any such labels and was not aware of the need for such labels. The Hospital Facilities Director also said that he did not observe the transporting company attach any labels to the boxed biohazardous waste.

4. On 1/14/15 at 3:30 P.M., the Hospital Facilities Director provided white tracking forms, dated between 1/2014 and 8/2014, to Surveyor #1. The Hospital Facilities Director said he contacted the biohazardous waste removal company for the forms and they were faxed to the Hospital that day. The Hospital Facilities Director said he had not reported the biohazardous waste removal company for not returning the white copies of the tracking forms within 30 days of trash removal, as required by State Sanitary Code Regulation.

Based on observations, interviews, and review of personnel files, the Hospital failed to ensure that the Infection Control Nurse (ICN) received proper education and training and that hand hygiene and personal protective equipment (PPE) infection control (IC) protocols were implemented for 9 Patients (#1, #2, #21, #20, #26, #29, #28, #29, #30) from a total sample of 36 Patients.
Findings include:

Review of the Hospital document titled "Hand Hygiene Information Sheet" (not dated), indicated that Hospital staff should "use alcohol based hand rub before and after patient contact, before donning gloves and after removing gloves."

Centers for Disease Control (CDC) and Prevention Guidelines for Hand Hygiene require staff to perform hand hygiene, before donning and after removal of gloves, before and after contact with the patients or their immediate care environment, even if gloves are worn, and after contact with contaminated surfaces, even if gloves are worn.

1. For Patients #1 and #2, observations of medication administration in the Inn Unit Nurses Station on 1/12/15 at 10:00 A.M., revealed that Registered Nurse (RN) #1 failed to perform hand hygiene between administering medications to each Patient.

Observation of the above medication passes revealed that RN #1 touched the outside of 2 drawers in the medication closet to obtain each patient's medications. Then RN #1 immediately administered medications first to Patient #1 and then to Patient #2.

RN #1 failed to perform hand hygiene after touching potentially contaminated surfaces (medication drawers) and before preparing each Patients' medications and again between Patient #1 and #2, as required.

Review of the personnel file of RN #1, for documentation of annual IC education for hand hygiene and blood borne pathogens, revealed that RN#1 lacked evidence of annual training for these required topics.

2. Observations in the Second Floor Housekeeping Closet of the Inn Unit on 1/12/15 at 10:30 A.M., revealed that Housekeeper #2 accessed the clean glove box and donned a pair of gloves. Housekeeper #2 failed to perform hand hygiene before accessing the glove box and donning the gloves.

Interview with Housekeepers #1 and #2 during the observation, both Housekeepers said that the last hand hygiene education that was provided to the housekeepers was "at least two to three years ago."

Review of the personnel files of Housekeepers #1 and #2, for documentation of annual IC education for hand hygiene and blood borne pathogens, revealed that neither Housekeeper #1 or #2 had any evidence of the above education.

The Hospital failed to ensure that policies for hand hygiene were implemented.

3. During interview on 1/13/15 at 10:45 A.M., the ICN said that she was in the role of ICN since 11/2013, just over one year. When asked by the Surveyor what her responsibilities included, the ICN said that she was the Utilization Review Director and "ICN is just a hat." The ICN continued, "I am only involved with (Department of) Nursing IC. I have never been involved with (the Departments of) Dietary or Housekeeping."

Surveyor then asked the ICN what training and education she had received for the ICN position? The ICN said,"I am an RN. (Training is) what I learned in Nursing School and over the years (of experience). I have had no formal (IC) training."

The ICN also said that currently the Hospital had not retained the services of an IC Consultant, so she had no one to go to for IC direction, advice or questions. The ICN also said that she did not conduct IC Hospital Rounds, or provide IC inservices and education to staff other than Department Nursing staff.

Review of the ICN's personnel file confirmed that she had no formal training in IC or ongoing IC education, training, or certification to oversee the infection control program.

4. During interview on 1/13/15 at 10:45 A.M., the ICN said that although the Hospital had IC policies, the policies had not been reviewed or revised since 2/2011. Additionally, the ICN said that the Hospital lacked policies and procedures relevant to construction, renovation, maintenance, demolition and repair, as required.

The ICN also said that the Hospital lacked post-exposure evaluation and follow-up protocol, following an exposure event (e.g., needle stick, staff contact with patients' blood or body fluids), as required by the Hospital Patient Safety Initiative Infection Control Tool.

During interview with the Director of Nursing (DON) on 1/14/15 at 3:00 P.M., the DON said that staff were responsible to follow-up with their personal physician and the Hospital did not perform that function.

5. For Patients #21, #26, #29, #28, #29 and #30, observations of medication administration in the Inn Unit Nurses Station on 1/14/15 from 9:10 A.M. to 10:00 A.M., revealed RN #7 had patient contact with each of the above Patients by touching their identification bracelets to verify their identity.

After touching the identification bracelet of each Patient, RN #7 then administered medications to each Patient. RN #7 failed to perform hand hygiene before and after each patient contact, although required by Hospital CDC Guidelines.

6. For Patients #20, #26, #28, and #29, observations from 10:50 A.M. to 11:15 A.M. on 1/14/15, in the Inn Unit, revealed that Mental Health Assistant (MHA) #2, was taking the Patients' blood pressures (BP), temperatures and pulses (heart rate). Although MHA #2 wore gloves, MHA #2 did not remove her gloves and perform hand hygiene before and after contact with each Patient, as required by CDC Guidelines and Hospital IC protocol.

Based on observation, interview, review of the Hospital's policies/procedures, personnel files, and infection control logs, the Hospital failed to consistently ensure an acceptable level of infection prevention practice related to adherence to infection control policies and procedures, hand hygiene, personal protective equipment (PPE), effective disinfection of equipment, and development and implementation of a routine environmental cleaning schedule. Findings included:

1. The hospital failed to sanitize the glucometer according to manufacturer's guidelines.

Review of the manufacturer's directions for use (MDFU) for the Hospital's glucometer under Cleaning and disinfecting guidelines, read, "Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide."

On 8/26/2010, the Centers for Disease Control (CDC) issued requirements for Infection Prevention during Blood Glucose Monitoring and Insulin Administration, supported by the Food and Drug Administration (FDA). These requirements that state fingerstick devices should never be used for more than one person. Whenever possible, point of care (POC) blood testing devices, such as a blood glucose meter, should be used only on one patient and not shared. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

2. Observation on the Hospital Unit on 1/12/2015 at 11:50 A.M., Registered Nurse #3 obtained Patient #10's finger stick blood sugar (POC) using the unit's glucometer. After use, the glucometer was wiped down with an alcohol wipe by RN #3 and returned to a basket, available for use on the next patient. According to RN #3, the glucometer was wiped down with an alcohol swab because the bleach wipes which are the appropriate disinfectant, were beyond their use date.

3. The Hospital failed to store medications in an appropriate location to prevent cross contamination (from a water source and cleaning agents).

Observation of the medication refrigerator for the Hospital Unit on 1/12/15 at 11:05 A.M., indicated that, in the Nurses Station, the medication refrigerator was located underneath a handwashing sink. The refrigerator was next to the handwashing sink's plumbing and 2 open spray bottles of disinfectant. RN #2 said the bottles of disinfectant were used to clean surfaces between patients. The top of the medication refrigerator also was laden with a layer of dust.

4. The Hospital failed to ensure that a nurse performed adequate handwashing prior to administering medications to a patient.

Observation of a medication pass with RN #5 on 1/13/15 at 11:50 A.M., RN #5 poured Patient #5's medications and then turned the handwashing sink faucet (a contaminated surface) with her right hand and filled a cup of water. She then shut off the faucet with her hand (contaminated her hand) and did not wash her hand. She then gave Patient #5 oral medications with her contaminated hand.

During an interview with RN #5 on 1/13/15 at 11:55 A.M., she was not aware that she had contaminated her hand, or how to shut off the handwashing sink faucet without contaminating her hands.


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5. Review of the Infection Control Plan dated as effective 7/3/2014, indicated the following;
Under the heading "Housekeeping:"
"Maintaining our facility in a clean and sanitary condition is an important part of our Blood Borne Pathogen Compliance Program. To facilitate this we have set up a written schedule for cleaning and decontamination of the various areas of the facility. The schedule provides the following information (this schedule can be found on the following page).

The area to be cleaned and decontaminated
Day and time of scheduled work
Cleaners and disinfectants to be used
Any special instructions that are appropriate.

Housekeeping staff is responsible for setting up our cleaning and decontamination schedule and making sure it is carried out within our facility."

Review of the enclosed cleaning schedule indicated that it was totally blank.

During interview with the Director of Facilities on 1/13/15/at 9:00 A.M., the Director of Facilities that he was new to his position as of 9/15/14, and that he was not given any training for his position except to shadow his predecessor for a month for only maintenance duties.

The Director of Facilities said that he had not developed a cleaning schedule, he never attended an IC inservice since his date of hire 6/2012. He said that he was given an Employees Handbook and nothing else. He was not trained on Universal Precautions, or contact precautions, all very applicable to Housekeeping Services.

The Director of Facilities said that he did not have a file on housekeeping staff for IC or housekeeping training. The Director of Facilities said that he never conducted any IC or housekeeping training of Housekeeping staff or monitored their hand hygiene or housekeeping practice. He said he was never told that he was responsible to do so.

6. Observations during the tour of the Inn Building on 1/12/15 from 9:45 A.M. to 11:15 A.M., indicated the following:

a. Observations of the First Floor Housekeeping Closet revealed a dry mop, dirty with stains and built-up layers of dust.

b. During interview with Housekeeper #1, during the tour, the Housekeeper said that she used the product Husky 1230 to clean and disinfect surfaces. Housekeeper #1 said she sprayed the surfaces to be cleaned and then wiped off the disinfectant with a paper towel.

Review of the manufacturer's directions for use (MDFU) of the Husky 1230, indicated to "Spray the surface for 3 to 4 seconds until the surface is wet. Allow to dry without wiping. Allow (Husky 1230) to contact surfaces for a minimum of 10 minutes" Housekeeper #1 did not follow MDFU.

Upon Surveyor inquiry at 10:10 A.M., Housekeeper #1 said she had not had an inservice on proper use of the Husky 1230 since she was hired, seven years ago.

c. Observations in the Inn Building of the Family Visiting Room and the Conference Room at 10:20 A.M. on 1/12/15, revealed that both rooms contained wicker furniture with cloth pillows and cushions. Housekeepers #1 and #2 said that staff routinely used the rooms to meet with patients and that families routinely visited with patients in the rooms so the furniture was considered a high touch area. ( CDC IC Guidelines require high touch area to be routinely disinfected).

When asked by the Surveyor how the furniture, pillows and cushions were cleaned, Housekeeper #2 said that she had never cleaned the furniture since it was first purchased over one year ago.

During the observation, two Staff were observed meeting with a patient in the Family Visiting Room.

d. Observation of the Second floor Housekeeping Closet at 10:45 A.M. on 1/12/15, indicated the following:

- The Housekeeping Closet was once a bathroom and contained a handwashing sink, linen closet and additional small storage area. The Housekeeping closet did not contain a floor sink for disposal of dirty water used to wash floors, as required by the Facilities Guidelines Institute for the Construction of Health Care Facilities.

Housekeeper #1 said that she disposed of dirty water outside the building in the grass or walked the floor washing bucket across the parking lot to the Occupational Training Building to dispose of the dirty water.

- The Housekeeping Closet floor was very dirty with paper, debris, dust balls, and built-up layers of dirt.

- Two feather dusters were observed in the closet. Housekeeper #2 said that she used one for high dusting (e.g., ceilings) and one for dusting doors and mop boards. Both dusters were dirty with stains and dust balls. Infection Control Standards of Practice prohibit dry dusting in Hospitals.

- Three patient pillows were stored directly on the floor in the linen closet.


7. Review of Hospital policy for cleaning patients' bedrooms after discharge indicated, "Clean dressers outside and inside drawers and cabinets with Jaws Disinfectant-Degreaser."

During interview on 1/12/14 at 11:00 A.M., upon Surveyor inquiry, Housekeeper #2 said that she cleaned patients' rooms after discharge as follows:

"The bed frame is cleaned with soap and water;
Inside bureau drawers are sprayed with Jaws Disinfectant-Degreaser;
The outside of the drawers and bureau are cleaned with furniture polish;
The bathroom sink and faucets are cleaned with Comet."

Housekeeper #2 did not adhere to Hospital policy and IC Standards of Practice as she failed to clean the bed frames and outside of the bureaus (high touch areas) with the disinfectant.

During interview on 1/12/15 at 12.25 P.M., the Director of Facilities said that he did not maintain documentation of IC and cleaning competencies for Housekeepers #1 and #2.

8. Observation of the Occupational Therapy Building, with the Facilities Director, on 1/13/15 at 2:00 P.M., revealed that all 12 pieces of exercise machines, utilized by patients, were dirty and dust laden. The Facilities Director said that the equipment had not been cleaned for some time.

Additionally, the floor in the Activities Room of the Occupational Therapy Building, was dirty with debris and layers of dust. The Facilities Director said the floor had not been cleaned for many months.

Based on documentation review and staff interview, the Hospital failed to reassess its discharge planning process on an ongoing basis.

Findings included:

1. Review of the the Hospital's Discharge Planning Policy on 01/13/15, did not include a process to reassess discharge planning services.

2. On 01/13/15 at 1:30 P.M., the Director of Clinical Services said that she conducts five patient chart audits a week to reassess the discharge planning services. The Director of Clinical Services also said that the results of the weekly chart audits are given to the Quality Assurance Program. However, review of the chart audit documentation indicated that a chart audit review had not been conducted. According to the Director of Clinical Services, she has not completed an audit in awhile and could not state when the last chart audits were completed.

Based on record review and interview, the facility failed to ensure that the social work assessments for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community.

Findings include:

A. Record Review

The psychosocial assessments of the following patients were reviewed (dates of evaluations are in parentheses): A3 (1/07/14); A4 (1/07/14); A5 (1/09/14); A11 (1/12/14); A13 (1/12/14); and A14 (1/12/14). This review revealed:

1. Patient A3: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote "will benefit from attending all groups."

2. Patient A4: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote "will benefit from attending all groups."

3. Patient A5: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote, "Would benefit from all groups in milieu."

4. Patient A11: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote, "would benefit from all groups in milieu and medication management."

5. Patient A13: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social workers wrote, "would benefit from all groups in milieu and aftercare referrals."

6. Patient A14: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker provided no commentary and left this section blank.


B. Staff Interview

An interview was conducted with the Director of Social Work on 1/13/15 at 12:40 p.m. In reviewing copies of the Psychosocial Assessments of the sample patients, the Social Work Director concurred that "Section C, Conclusions and Recommendations" was not completed in keeping with probes provided on the template document which advised the social worker to comment on "anticipatory necessary steps for discharge to occur" or on "high risk patient and/or family issues requiring early treatment planning and immediate intervention" or on "specific community resources/support systems for utilization in discharge planning."

Based on record review and interview, the facility failed to ensure that the screening neurological examinations indicated how the functional status of each of the cranial nerves, cerebellar, sensory, and deep tendon reflexes was assessed for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14). Absence of this detail can adversely affect clinical decision-making as to the need for more detailed neurologic examination and work-up.

Findings include:

A. Record Review

The History, Physical and Psychiatric Evaluations of the following patients were reviewed (dates of evaluations are in parentheses): A3 (1/06/14); A4 (1/07/14); A5 (1/09/14); A11 (1/09/14); A13 (1/09/14); and A14 (1/09/14). This review revealed:

1. Patient A3: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 6, 2015, cranial nerves I through XII are described as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

2. Patient A4: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 7, 2015, cranial nerves I, II, and V through XII are reported as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

3. Patient A5: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 9, 2015, cranial nerves I, II, and V through XII are reported as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

4. Patient A11: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 9, 2015, cranial nerves I, II, and V through XII are reported as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

5. Patient A13: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 9, 2015, cranial nerves I, II, and V through XII are reported as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

6. Patient A14: In the Screening Neurological Examination section of the History, Physical and Psychiatric Evaluation dated January 9, 2015, cranial nerves I, II, and V through XII are reported as "grossly within normal limits" without any indication of how the examination was performed. Sensation is noted as "grossly within normal limits" without an indication of what was assessed. Deep Tendon Reflexes are reported as "2+" without indicating which reflexes were examined.

B. Staff Interview

An interview was conducted with the Medical Director on 1/13/2015 at 11:00 a.m. The Screening Neurological Examination sections of sample History, Physical and Psychiatric Evaluations were reviewed and discussed. The Medical Director agreed that there was "no description of how the tests were performed."

Based on record review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans (MTPs) based on the individual needs of patients for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14). Specifically, the facility used pre-printed treatment plan forms based on specific problems. The facility used the problems of "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal" for all six (6) patients regardless of variations in their diagnosis, problems and moods. Three (3) of six (6) active sample patients (A5, A13 and A14) did not have Psychiatric Interventions by physicians on the MTPs. Failure to individualize the treatment plans of patients can prevent staff from knowing how to address each patient's specific problem(s) which can result in unmet needs and potentially prolong lengths of hospitalization.

Findings include:

A. Record Review

1. Facility policy, no number, titled "Policy on Inter-Disciplinary Individual Treatment Plan for Hospital Level of Care", dated 10/14, stated: "The treatment plan includes the assessment of needs and strengths. It is developed by inter-disciplinary treatment team with maximum possible participation of the patient or his/her legally authorized representative" --- "The client's problems, strengths, needs, abilities and preferences described in behavioral terms [sic]." Failure of the staff to individualize the MTPs by not consistently adding specific patients' needs and outcomes made all the plans the same or similar in content.

2. Active sample patient A3 was admitted on 1/6/15. The AXIS I diagnoses on the MTP, dated 1/7/15 were "Alcohol Dep. [Dependence], Cocaine Dep.' and 'PTSD [Post Traumatic Stress Disorder]." The psychiatric problems on the MTP were "Depressive Symptoms" and "Substance Dependence/ Potential for Acute Withdrawal." "Behavioral Manifestation Observations" were:

Problem 1- "Depressive Symptoms": "Suicidal ideations which patient denies on admission; depressed mood; decreased appetite and concentration."

Problem 2- "Substance Dependence/Potential for Acute Withdrawal from ETOH [alcohol]/cocaine as evidenced by: current use, positive toxicology screen, history of withdrawal" and "social and occupational impairment as evidenced by [blank space]."

3. Active sample patient A4 was admitted on 1/7/15. The AXIS I diagnoses on the MTP, dated 1/7/15 were: "Polysubstance Dependence, Depressive Disorder, NOS [not otherwise specified]" and "Depressive Disorder, NOS." The psychiatric problems on the MTP were: "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal." "Behavioral manifestation/observations" were:

Problem #1- "Depressive Symptoms: suicidal ideation which the patient denies on admission; depressed mood; decreased appetite and decreased sleep."

Problem #2- "Substance Dependence/Potential for Acute Withdrawal from ETOH, Heroin, cocaine as evidenced by: Current use, positive toxicology screen, active withdrawal symptoms, history of withdrawal" and "history of DT's[delirium tremens] as evidenced by WD [withdrawal] seizure {2013)."

4. Active sample patient A5 was admitted to 1/9/15. The AXIS I diagnoses on the MTP, dated 1/9/15 were: "Opioid Dependency" and "Mood DO, NOS [disorder, not otherwise specified]." The psychiatric problems on the MTP were: "Depressive Symptoms" and Substance Dependence/Potential for Acute Withdrawal." "Behavioral manifestation/observations" were:

Problem #1- "Depressive Symptoms: suicidal ideations which patient denies on admission; depressed mood; decreased appetite; decreased sleep; anhedonia; decrease energy; decreased concentration; decreased concentration" and "psychomotor retardation."

Problem #2- "Substance Dependence/Potential for Acute Withdrawal as evidenced by: current use, positive toxicology screen, drug seeking behavior, active withdrawal symptoms" and "social and occupational impairment as evidenced by [blank space]."

There were no physician interventions for the psychiatric problems on the MTP, causing it not to be interdisciplinary.

5. Active sample patient A11 was admitted on 1/9/15. The AXIS I diagnoses on the MTP, dated 1/12/15 were: "Mood Disorder, NOS" and "Polysubstance Dependence." "Behavioral manifestation/observations" were:

Problem #1- "Depressive Symptoms": suicidal ideation which patient denies on admission; depressed mood and decreased appetite."

Problem #2- "Substance Dependence/Potential for Acute Withdrawal" from heroin as evidenced by current use, positive toxicology screen; history of withdrawal" and "social and occupational impairment as evidenced by blank space."

6. Active sample patient A13 was admitted on 1/9/15. The AXIS I diagnoses on the MTP, dated 1/12/15, were "Major Depression, recurrent moderate; Alcohol Dependency" and "Anorexia Nervosa." "Behavior manifestation/observations" were:

Problem #1- "Depressive symptoms": "Depressed mood, decreased appetite and decreased sleep."

Problem #2- "Substance Dependence/Potential for Acute Withdrawal from ETOH as evidenced by: current use" and "social and occupational impairment as evidenced by [blank space]."

There were no physician interventions for the psychiatric problems on the MTP, causing it not to be interdisciplinary.

7. Active sample patient A14 was admitted on 1/9/15. The AXIS I diagnoses on the MTP, dated 1/12/15 were: "Alcohol Dependence" and "Post Traumatic Stress D/O." "Behavior manifestation/observations" were:

Problem #1- "Depressive Symptoms": suicidal ideation which patient denies on admission; depressed mood; decreased appetite" and "decreased sleep."

Problem #2- "Substance Dependence/Acute Withdrawal Potential from ETOH as evidenced by: current use" and "history of use as evidenced by [blank space]."

There were no physician interventions for the psychiatric problems on the MTP, causing it not to be interdisciplinary.

B. Interview

In an interview on 1/13/15 at 12:00 p.m., the lack of individualization of the pre-printed treatment plan forms was discussed with the Director of Nursing. She stated that the pre-printed forms were not the problem. She felt the problem was the way the clinical staff filled out the forms.

Based on record review and interview, the facility failed to develop Master Treatment plans (MTPs) that included long-term goals (LTG) and/or short-term goals (STG) that were stated in observable, measureable patient behaviors to be achieved for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient's behaviors.

Findings include:

A. Record Review

1. Facility policy, no number, titled "Policy on Inter-disciplinary/Individual Treatment Plan for Hospital Level of Care", dated 10/14, stated: "Each treatment team includes the following elements" --- "Service to be provided; Service goals, described in behavioral teams." There was no additional information on goal formation and content. Many of the pre-printed long and short term goals were difficult to measure. Most of the information provided did not expand on specific behaviors to be observed to help determine patient outcome.

2. Active sample patient A3, MTP dated 1/7/15, had the following non-measureable long and/or short term goals for the problem of "Depressive Symptoms":

LTGs- "Person served will report stable mood." "Person served will remain free of suicidal ideation during hospitalization."

STG- "Person served will demonstrate a 50% improvement in nutritional intake by day three (3) of hospitalization."

For the problem of "Substance Dependence/Potential for Acute Withdrawal":

LTG- "Person served will complete detoxification protocol without complications by day four (4)."

STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

3. Active sample patient A4, MTP dated 1/7/15, had the following non-measureable log and/or short term goals for the problem of "Depressive Symptoms":

LTGs- "Person will report stable mood. Person served will remain free of suicidal ideation during hospitalization."

STG- "Person served will demonstrate a 50% improvement in nutritional intake in day three (3) of hospitalization. "

For the problem of "Substance/Dependence/Potential for Acute Withdrawal":

LTG- "Person served will complete detoxification protocol without complications by day five (5)."

STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

4. Active sample patient A5, MTP dated 1/9/15, had the following non-measureable long and/or short term goals for the problem of "Depressive Symptoms":

LTGs- "Person served will report stable mood. Person served will remain free of suicidal ideation during hospitalization. Person served will report energy level at baseline."

STG- "Person served will report I improved energy level by day three (3) of hospitalization."

For the problem of "Substance Dependence/Potential for Acute Withdrawal":

LTG- "Person served will complete detoxification protocol without complications by day five (5).

STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

5. Active sample patient A11, MTP dated 1/12/15, had the following non-measureable long and/or short term goals for the problem of "Depressive Symptoms":

LTGs- "Person served will report stable mood. Person served will remain free of suicidal ideations during hospitalization."

STG- "Person served will demonstrate 50% improvement in nutritional intake by day three (3) of hospitalization."

For the problem of "Substance Dependence/Potential for Acute Withdrawal":
LTG- "Person served will complete detoxification protocol without complications by day four (4)."
STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

6. Active sample patient A13, MTP dated 1/12/15, had the following non-measureable long and/or short term goal for the problem of "Depressive Symptoms":
LTG- "Person served will report stabile mood."
STG- "Person served will demonstrate 50% improvement in nutritional intake by day three (3) of hospitalization."

For the problem of "Substance Dependence/Potential for Acute Withdrawal":
LTG- "Will complete detoxification protocol without complication by day five (5)."
STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

7. Active sample patient A14, MTP dated 1/12/15, had the following non-measureable long and/or short term goals for the problem of "Depressive symptoms":

LTGs- "Person served will report stable mood. Person served will remain free of suicidal ideations during hospitalization."

STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

For the problem of "Substance Dependence/Potential for Acute Withdrawal":
LTG- "will complete detoxification protocol without complication by day five (5)."

STG- "Person served will exhibit elimination of withdrawal symptoms for two (2) days prior to discharge."

B. Interviews

In an interview on 1/13/15 at 12:00 p.m., the lack of individualization of pre-printed treatment plan forms was discussed with the Director of Nursing. She stated that the pre-printed forms were not the problem. The way the clinical staff filled out the forms was the issue.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) interventions consistently addressed specific treatment needs for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13 and A14). The staff interventions in the MTPs were stated primarily as generic discipline functions. The facility used pre-printed treatment plans based on two (2) identifying psychiatric problems- "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal." The pre-printed interventions were the same or similar for each patient regardless of each patient's individual needs. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problem(s) and may result in prolonged hospitalization.

Findings include:

A. Record Review

1. Facility policy, no number, titled "Policy on Inter-Disciplinary Individual Treatment Plan for Hospital Level of Care", dated 10/14, stated "Each treatment team includes the following elements: the client's problems, strengths, needs, abilities and preferences described in behavioral terms." There was no specific reference to staff interventions and what information (such as a specific purpose of a group for each patient and a specific focus) should be included in this one page treatment plan policy. The pre-printed intervention choices on the MTPs were generic and did not address the specific needs of each patient.

2. Active sample patient A3, MTP dated 1/7/15. Patient's problem identified on the MTP was "¿ [increased depression]/anxiety, cocaine".

For the problem of "Depressive Symptoms" some interventions were: the physician, nurse and social worker will "assess and document patient's mental status including level of depression and suicidality." Focus of intervention/modality- "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

The physician and nurse will: "Administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Focuses of intervention were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medications ordered to address depressive symptoms was blank.

OT/TA (Occupational Therapist/Therapeutic Assistant)- The intervention was "Participation in daily OT/TA programming." Focus- "Daily goals group and wrap up to: [space was blank]." Second focus- "OT/AT groups to assist in developing living skills, coping skills, leisure skills daily."

Social Work Interventions: "Psychiatric groups, Coping Skills/Self-esteem groups and Discharge groups." Focus- "ID [identify] coping skills, triggers." Frequency- "a minimum of four (4) groups per week."

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite" and "decreased concentration."

Physician and nurse intervention/modality was: "Implement protocol for substance of abuse/dependence." Focus- "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox."

Physician and nurse interventions: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication- section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

OT/TA Intervention/Modality- "Participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank]." "OT/AT groups to assist in developing living skills, coping skills."

Social Work Interventions/Modality: "Substance Abuse group, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "Create relapse per plan". Frequency- "A minimum of four (4) groups per week."

3. Active sample patient A4, MTP dated 1/7/15. Problems identified on the MTP were: "¿[decreased] mood, under eating, sleep difficulty, SI [suicide ideation] with plan to overdose."

For the problem of "Depressive Symptoms" some interventions were: the physician, nurse and social worker "will assess and document patient's mental status including level of depression and suicidality." Focus of intervention/modality- "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

The physician and nurse will: "Administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Focuses of interventions were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medications ordered to address depressive symptoms was blank.

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation which patient denied on admission, depressed mood, decreased appetite" and "decreased concentration."

Physician and nurse intervention/modality was: "Implement protocol for substance of abuse/dependence." focuses of intervention/modality- "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox."

Physician and nurse interventions: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- " Provide treatment for withdrawal." Frequency section was blank.

OT/TA Intervention/Modality- "Participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank]." "OT/AT groups to assist in developing living skills, coping skills."

Social Work Interventions/Modality- "Substance Abuse group, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "Create relapse per plan". Frequency- "A minimum of four (4) groups per week."

4. Active sample patient A5, MTP dated 1/9/15. Problems identified on MTP were: "decrease sleep and appetite, increase anxiety, anhedonia [inability to experience pleasure], decrease energy, reports increase in heroin abuse."

For the problem of "Depressive symptoms", there were no physician interventions. The nurse and the social work intervention was: "Staff will assess and document patient's mental status including level of depression and suicidality." Focus- "to ensure patient safety and assess progress toward stabilization of presenting symptoms." Frequency- "at least daily."

OT/TA Intervention- "Participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank]." "OT/AT groups to assist in developing living skills, coping skills."

Social Work Intervention/Modalities: "Psychiatric groups, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "Improve mood." Frequency- "a minimum of four (4) groups per week."

For the problem of "Substance Dependence/Potential for Acute Withdrawal"- there were no physician interventions. The nurse intervention was: "Implement protocol for substance of abuse/dependence," focus- "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication monitor for signs and symptoms of detox."

Nurse intervention- "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

OT/TA Intervention/Modality- "Participation in daily OT/TA programming." Focus- "Daily goals group and wrap up to: [section was blank]." "OT/AT groups to assist in developing living skills, coping skills."

Social Work Interventions/Modalities: "Substance Abuse group, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus was blank. Frequency- "a minimum of four (4) groups per week."

5. Active sample patient A11, MTP dated 1/12/15. Problems identified on MTP were: "Decreased mood, increased anxiety, suicidal ideation with plan to OD [over dose]."

For the problem of "Depressive Symptoms" some interventions were: the physician, nurse and social worker will "assess and document patient's mental status including level of depression and suicidality." Focus- "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

The physician and nurse will: "administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Focuses of intervention were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medications section to address depressive symptoms was blank.

OT/TA (Occupational Therapist/Therapeutic Assistant)- The intervention was "participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to": was blank. OT/AT groups to assist in developing living skills, coping skills, leisure skills" daily.

Social Work Interventions: "Psychiatric groups, Coping Skills/Self-esteem groups and Discharge groups." Focus- "Improve mood/decrease anxiety." Frequency- "a minimum of four (4) groups per week."

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite and "decreased concentration."

Physician and nurse intervention/modality was "Implement protocol for substance of abuse/dependence." Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox."

Physician and nurse interventions: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

OT/TA Intervention/Modality- "Participation daily OT/TA programming." Focuses- "Daily goals group and wrap up to: [section was blank]." OT/AT groups to assist in developing living skills, coping skills."

Social Work Interventions/Modalities: - "Substance Abuse group, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "ID [identify] triggers, encourage relapse prevention goals". Frequency- "A minimum of four (4) groups per week."

6. Active sample patient A13, MTP dated 1/12/15. Problems identified on MTP were: "Increased depression and anxiety, decrease appetite, decreased sleep."

For the problem of "Depressive Symptoms" some interventions were: the nurse and social worker will "assess and document patient's mental status including levels of depression and suicidality." Focus- "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

There were no physician interventions.

A nurse intervention was "Implement detox protocol or substance of abuse/dependence." Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox." Frequency- "Daily and prn [as needed]."

Nurse interventions: "administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Medication listed- "Librium." Focus of interventions were: "Provide treatment for withdrawal symptoms." Frequency- "Per protocol."

OT/TA (Occupational Therapist/Therapeutic Assistant)- The intervention was "participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank]. OT/AT groups to assist in developing living skills, coping skills, leisure skills" daily."
Social Work Interventions: "Psychiatric groups, Coping Skills/Self-esteem groups and Discharge groups." Focus- "Address all goals of relapse prevention." Frequency- "a minimum of four (4) groups per week."

7. Active sample patient A14, MTP dated 1/12/15. Problems identified on MTP were: "Decrease mood, under eating, sleep difficult, SI ø plan [suicidal ideation. No plan]."

For the problem of "Depressive Symptoms", there were no physician interventions.

The nurse and the social work intervention was: "Staff will assess and document patient's mental status including level of depression and suicidality." Focus- "to ensure patient safety and assess progress toward stabilization of presenting symptoms." Frequency- "at least daily."

OT/TA Intervention- OT/TA (Occupational Therapist/Therapeutic Assistant)- The intervention was "participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank.]" "OT/AT groups to assist in developing living skills, coping skills, leisure skills daily."

Social Work Intervention/Modalities were: "Psychiatric groups, Coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "ID coping skills and triggers." Frequency- "a minimum of four (4) groups per week."

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite" and "decreased concentration."

A nurse intervention/modality was "Implement protocol for substance of abuse/dependence," focuses were: - "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication monitor for signs and symptoms of detox."

Nurse interventions were: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- " Provide treatment for withdrawal." Frequency section was blank.

OT/TA Intervention/Modality- "Participation in daily OT/TA programming." Focuses were: "Daily goals group and wrap up to: [section was blank]." "OT/AT groups to assist in developing living skills, coping skills."

Social Work Interventions/Modalities were: "Substance Abuse group, coping Skills/Self-esteem groups, Discharge Planning groups." Focus- "Create relapse per plan". Frequency- "A minimum of four (4) groups per week."

B. Interviews

1. In an interview on 1/13/15 at 12:00 p.m., the lack of individualization of pre-printed treatment plan forms was discussed with the Director of Nursing. She stated that the pre-printed forms were not the problem. The way the clinical staff filled out the forms was the issue.

2. In an interview on January 1/1315 at 11:00 a.m., several of the sample treatment plans were reviewed with the Medical Director, with particular emphasis on objectives that were not measurable, and interventions that were not individualized or linked to specific problems and objectives. The Medical Director stated: "I see what you're saying"..."I have some ideas on how we can remedy this."

Based on record review and interview, the facility failed to include the full names of the various disciplines who were responsible for the interventions of the Master Treatment Plans (MTPs). The signatures of the various disciplines, that were located next to the intervention and/or under the section of the MTP titled- "This treatment plan was completed by the following team members", were either absent, had only initials, or first initial and last name which were all illegible. This practice makes it difficult to clearly monitor and hold responsible staff accountable for seeing that specific interventions are carried out.

Findings include:

A. Record Review

None of the following six (6) active sample patients' Master Treatment Plan (dates of the MTPs' in parenthesis) had legible names of all accountable discipline who were responsible for seeing that interventions were carried out: A3 (1/715), A4 (1/7/15), A5 (1/9/15), A11 (1/12/15), A13 (1/12/15) and A14 (1/12/15).

B. Interview

In an interview on 1/12/15 at 2:35 p.m., the difficulty of reading the names of the disciplines on the MTPs who were being held accountable for seeing that the interventions were being carried out was discussed with the Nursing Director. She did not dispute the findings.

Based on record review, observation and interview, the facility failed to provide active treatment, including alternative intervention for two (2) of six (6) active sample patients (A3 and A11) who were not motivated to consistently attend the groups offered on the unit. Rather than providing individualized treatment to meet the patients' needs, the patients were allowed to lie on their beds or wander around the unit during the hours when groups were held. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement.

Findings include:

A. Active Sample Patient E3

1. Patient A3 was admitted on 1/6/15. The Psychiatric Evaluation, dated 1/6/15, stated that A3's chief complaint was agoraphobia [anxiety where sufferers perceive certain environment as dangerous or uncomfortable]. The reasons for admission were: "Anxiety, depression, and substance abuse. Appears motivated for treatment "Under" mental status examination "was" understands need for help with problems other approaches have failed to address. Understands the need to cooperate with treatment."

2. On 1/12/15 at 1:00 p.m., during a group on depression, A3 was observed sitting in the room where the group was held, but s/he arrived late and did not participate in the group.

3. The Unit Daily Schedule provided five (5) group activities between the hours of 8:15 a.m. and 3:00 p.m. The groups were 8:15-9:15 a.m.- "Unit Group", 9:30-10:15 a.m.- "Unit Group", 10:45-11:30 a.m.- "Group",1:00 p.m.-1:45 p.m.- "Group" and 2:15 p.m.-3:00 p.m.- "Group".

4. In an interview on 1/12/15 around 10:00 a.m., RN #2 stated that there was one unit schedule for all patients on the unit and all patients were expected to attend the groups offered.

5. The therapeutic program's group notes from 1/7/15 to 1/9/15 showed that A3 attended only one (1) group out of twelve (12) offered.

6. "Rounds shift" that documents patients' where abouts every 30 minutes, 24 hours a day, showed A3 primarily in bedroom or in Dayroom during the times groups were held.

7. AN update of A3's MTP, dated 1/9/15, showed no revisions on the plan addressing his/her problem of poor group attendance at most of the scheduled groups.

B. Active sample patient A11

1. Active sample patient A11 was admitted on 1/9/15. The Psychiatric Evaluation, dated 1/9/15, stated that A11had "called 911 to have an ambulance transport him/her to the emergency room where s/he stated that s/he had suicidal ideation with plan to overdose. S/he gave history of being medication noncompliant over the past two (2) weeks and feeling suicidal over the past several days. A11 has a history of about 12 Psychiatric admissions to address mood disorder."

2. During an interview with A11 on 1/12/15 at 12:10 p.m., s/he was asked what s/he had done over the weekend on the unit. The patient stated s/he had slept all day, both days. When asked why s/he did not attend any groups, A11 stated "I don't get anything out of the groups."

3. During the group on Depression, held 1/12/15 from 1:00 p.m. to 1:45 p.m. on the unit, the surveyor left the group around 1:30 p.m. to see what A11 was doing. A11 was observed lying quietly on bed with eyes closed.

4. On 1/13/15 around 9:30 a.m., when RN #1 was asked to provide the Therapeutic Program Group Notes on A11, RN #1 stated, "There are no group notes as A11 has not attended any groups."

5. A review of the unit's round sheet for the period of 1/9/15 to 1/12/15 showed that A11 spent most of his/her time in bed during group times.

6. Patient A11's MTP, dated 1/12/15, did not address patient's lack of group attendance or what alternative activities could be provided to patient.

B. Interview

1. In an interview on 1/13/15 around 9:50 a.m., MHT #1 was asked what s/he did when patients did not attend group. S/he stated "We strongly encourage them to attend. We turn off the television during group time and offer them [patients] literature on the group or a choice of journaling."

2. In an interview on 1/13/15 around 10:30 a.m., RN #1 was asked what the staff did when patients refused to attend groups. RN #1 stated, "We encourage all patients to attend group. If they don't want to, we offer to sit with them and talk."

Based on record review and interview, the facility failed to ensure that the qualifications of doctors of medicine and osteopathy were adequate to provide essential psychiatric services. Questionable competency in psychiatry compromises the ability to accurately diagnose and formulate a plan of care for individuals seeking admission to the facility.

The findings include:

A. Record Review

1. The credentials file of MD1, a plastic surgeon by training and experience who provides on-call coverage for the facility, did not demonstrate how competency to perform psychiatric admission examinations and provide an initial psychiatric plan of care was ascertained. In addition, the section on "Are there any areas or skills that need additional or upgrading of training [sic]...or close supervision," in the "Competency Evaluation and Training Needs Assessment" completed by the Medical Director in reviewing MD1's application for appointment indicated "CMEs in psychiatry, assistance with admissions, and help with documentation" were needed.

2. The 2nd Quarter 2013 Professional Staff Review (performance review) of MD1, dated 7/22/13, indicated an "unsatisfactory" rating in the category "patient admission evaluation." The written comment provided by the Medical Director was "needs help with diagnoses and DSM [psychiatric diagnostic manual]." Continued privileges were recommended.

3. The 4th Quarter 2013 Professional Staff Review of MD1, dated 2/10/14, indicated "unsatisfactory" ratings in the category "availability and responsiveness to nursing staff " and in the category "timely arrival on duty. Timely record completion" The Medical Director's written comment was "problems not showing up on time." Continued privileges were recommended.

4. The 3rd Quarter 2014 Professional Staff Review of MD1, undated, indicated "unsatisfactory" ratings in all four categories (patient admission evaluation; weekend/holiday progress notes; availability and responsiveness to nursing staff; and Timely arrival on duty. Timely record completion). Continued privileges were not recommended, however MD1 continued to perform on-call duties.

B. Staff Interview

1. An interview was conducted with the Medical Director on January 13, 2015 at 11:00 a.m. When queried on whether additional supervision was provided to MD1 or whether the recommended additional continuing medical education in psychiatry had been obtained by MD1, the Medical Director stated "No, we don't have that."

2. An interview was conducted with the Human Resources Director on January 13, 2015 at 1:30 p.m. When asked if there were any human resources documents indicating that MD1 had participated in continuing medical education in psychiatry to meet the competency issues raised, she indicated "No, there are no additional records."

Based on record review and interview, the Medical Director failed to evaluate and monitor patient care being provided to patients. Specifically, the Medical director failed to:

I. Develop and document comprehensive multidisciplinary treatment plans (MTPs) based on the individual needs of patients for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13, and A14). Specifically, the facility used preprinted treatment plan forms based on two (2) specific problems. The facility used the problems of "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal" for all six (6) patients regardless of variations in their diagnosis, problems and moods. Three (3) of six (6) active sample patients (A5, A13 and A14) did not have psychiatric interventions by physicians on the MTPs, causing those to not be Interdisciplinary. Failure to individualize the treatment plans of patients can prevent staff from knowing how to address each patient's specific problems which can result in unmet needs and potentially prolong lengths of hospitalization. (Refer to B118).

II. Develop Master Treatment plans (MTPs) that included long-term goals (LTG) and/or short-term goals (STG) that were stated in observable, measureable patient behaviors to be achieved for six (6) of six (6) active sample patients (A3, A4, 5, A11, A13, and A14). This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions based on changes in patient's behaviors. (Refer to B121).

III. Ensure that the Master Treatment Plan (MTP) interventions consistently addressed specific treatment needs for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13 and A14). The staff interventions in the MTPs were stated primarily as generic discipline functions. The facility used pre-printed treatment plans based on two (2) identifying psychiatric problems- "Depressive Symptoms" and "Substance Dependence/Potential for Acute Withdrawal." The pre-printed interventions were the same or similar for each patient regardless of each patient's individual needs. Failure to document specific treatment approaches interferes with the assurance of consistency of approach to each patient's problem(s) and may result in prolonged hospitalization. (Refer to B122).

IV. Provide active treatment, including alternative interventions for two (2) of six (6) active sample patients (A3 and A11) who were not motivated to consistently attend the groups offered on the unit. Rather than providing individualized treatment to meet the patients' needs, the patients were allowed to lie on their beds or wander around the unit during the hours when group were held. Failure to provide active and appropriate treatment for patients results in the patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their improvement. (Refer to B125).

V. Ensure that the qualifications of doctors of medicine and osteopathy were adequate to provide essential psychiatric services. Questionable competency in psychiatry compromises the ability to accurately diagnose and formulate a plan of care for individuals seeking admission to the facility. (Refer to B142).

B. Staff Interview

An interview with the Medical Director was conducted on January 13, 2015 at 11:00 a.m. The Screening Neurological Examination sections of sample History, Physical and Psychiatric Evaluations were reviewed and discussed. The Medical Director agreed that there was "no description of how the tests were performed."

Several of the sample treatment plans were reviewed with the Medical Director, with particular emphasis on objectives that were not measurable, and interventions that were not individualized or linked to specific problems and objectives. The Medical Director stated: "I see what you're saying"..."I have some ideas on how we can remedy this.

When queried on whether additional supervision was provided to MD1, given the questions on psychiatric competency, or whether the recommended additional continuing medical education in psychiatry had been obtained by MD1, the Medical Director stated "No, we don't have that" and "when there were issues, the nursing staff would contact me."

Based on record review and interview, the Nursing Director failed to ensure the quality and appropriateness of patient care provided by nursing staff. Specifically the Nursing Director failed to ensure that nursing staff provided individualized Master Treatment plan interventions that were specific to each patient's problems and needs. Nursing interventions were generic monitoring and discipline functions to be performed by a nurse. Because the Master Treatment plans were pre-printed and based on two (2) specific problems (depression and substance abuse), patients had identical and/or similarly worded interventions. These deficiencies result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and fail to provide guidance to staff regarding the specific modalities needed and/or purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Active sample patient A3, MTP dated 1/7/15, patient's problem identified on the MTP was "¿ [increased depression]/anxiety, cocaine".

For the problem of "Depressive Symptoms" A nurse interventions was: "will assess and document patient's mental status including level of depression and suicidality." Focuses of intervention were: "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

Nurse will: "Administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Focuses were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medications ordered to address depressive symptoms was blank.

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite and "decreased concentration."

Nurse intervention/modality was "Implement protocol for substance of abuse/dependence." Focuses were- "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication monitor for signs and symptoms of detox."

Nurse interventions- "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

2. Active sample patient A4, MTP dated 1/7/15. Problems identified on the MTP were: "¿ [decreased] mood, under eating, sleep difficulty, SI [suicide ideation] with plan to overdose."

For the problem of "Depressive Symptoms" some nurse interventions were: "The nurse will assess and document patient's mental status including levels of depression and suicidality"
The nurse will: "administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Focuses of interventions were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medication section to address depressive symptoms was blank.

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were "Suicidal ideation which patient denied on admission, depressed mood, decreased appetite and "decreased concentration."

Nurse intervention/modality was "Implement protocol for substance of abuse/dependence." Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox."

Nurse interventions: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

3. Active sample patient A5, MTP dated 1/9/15. Problems identified on MTP were: "decreased sleep and appetite, increased anxiety, anhedonia [inability to experience pleasure], decreased energy, reports increase in heroin abuse."

For the problem of "Depressive symptoms", the nurse intervention was: "Staff will assess and document patient's mental status, including level of depression and suicidality. "Focuses: "to ensure patient safety and assess progress toward stabilization of presenting symptoms." Frequency- "at least daily."

For the problem of "Substance Dependence/Potential for Acute Withdrawal"- the nurse intervention was: "Implement protocol for substance of abuse/dependence," Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication monitor for signs and symptoms of detox."

Nurse interventions were: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

4. Active sample patient A11, MTP dated 1/12/15. Problems identified on MTP were: "Decreased mood, increased anxiety, suicidal ideation with plan to OD [over dose]."

For the problem of "Depressive Symptoms" nurse intervention was: "The nurse will assess and document patient's mental status including levels of depression and suicidality." Focuses were- "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

Nurse will: "Administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance. Medication education." Focuses were: "Provide treatment for depressive symptoms. Educate patient on side effects, benefits and risk of meds." List of medications section to address depressive symptoms was blank.

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite and "decreased concentration."

Nurse intervention/modality was "Implement protocol for substance of abuse/dependence." Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox."

Nurse interventions were: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

5. Active sample patient A13, MTP dated 1/12/15. Problems identified on MTP were: "Increased depression and anxiety, decrease appetite, decreased sleep."

For the problem of "Depressive Symptoms" Nurse Intervention was: The nurse will "assess and document patient's mental status including levels of depression and suicidality." Focuses were: "to ensure patient safety and to assess progress toward stabilization of presenting symptoms at least daily."

Nurse intervention was "Implement detox protocol or substance of abuse/dependence." Focuses were: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication, monitor for signs and symptoms of detox." Frequency- "Daily and prn [as needed]."

Nurse interventions: "Administer medications as prescribed. Assess patient knowledge and educate patient. Monitor for compliance, medication education." Medication listed was "Librium." Focus of intervention was: "Provide treatment for withdrawal symptoms." Frequency- "Per protocol."

6. Active sample patient A14, MTP dated 1/12/15. Problems identified on MTP were: "Decrease mood, under eating, sleep difficult, SI ø plan [suicidal ideation. No plan]."

For the problem of "Depressive symptoms", the nurse interventions were: "Staff will assess and document patient's mental status including level of depression and suicidality." Focuses were- "to ensure patient safety and assess progress toward stabilization of presenting symptoms." Frequency- "at least daily."

For the problem of "Substance Dependence/Potential for Acute Withdrawal", problems identified were: "Suicidal ideation" which patient denied on admission, depressed mood, decreased appetite and "decreased concentration."

Nurse intervention: "Implement protocol for substance of abuse/dependence." Focuses of intervention: "Ensure safe detox, provide daily assessment, evaluate, adjust and assess efficacy of medication monitor for signs and symptoms of detox."

Nurse interventions were: "Administer medication as prescribed; assess patient knowledge and educate patient, monitor for compliance; medication education." List of medication section was blank. Focus- "Provide treatment for withdrawal." Frequency section was blank.

B. Interview

In an interview on 1/13/15 at 12:00 p.m., the lack of individualization of the pre-printed treatment plan forms was discussed with the Director of Nursing. She stated that the pre-printed forms were not the problem. She felt the problem was the way the clinical staff filled out the form.

Based on record review and interview, the Director of Social Work failed to ensure that the social work assessments for six (6) of six (6) sample patients (A3, A4, A5, A11, A13, and A14) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community.

Findings include:

A. Record Review

The psychosocial assessments of the following patients were reviewed (dates of evaluations are in parentheses): A3 (1/07/14); A4 (1/07/14); A5 (1/09/14); A11 (1/12/14); A13 (1/12/14); and A14 (1/12/14). This review revealed:

1. Patient A3: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote "will benefit from attending all groups."

2. Patient A4: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote "will benefit from attending all groups."

3. Patient A5: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote, "Would benefit from all groups in milieu."

4. Patient A11: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker wrote "would benefit from all groups in milieu and medication management."

5. Patient A13: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social workers wrote "would benefit from all groups in milieu and aftercare referrals."

6. Patient A14: In the psychosocial assessment's section "C. Conclusions and Recommendations: Anticipated necessary steps for discharge to occur. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay. Specific community resources/support systems for utilization in discharge planning (e.g. housing/living arrangements, financial aid and aftercare treatment sources)," the social worker provided no commentary and left this section blank.


B. Staff Interview

An interview was conducted with the Director of Social Work on 1/13/15 at 12:40 p.m. In reviewing copies of the Psychosocial Assessments of the sample patients, the Social Work Director concurred that "section C, Conclusions and Recommendations" was not completed in keeping with probes provided on the template document which advised the social worker to comment on "anticipatory necessary steps for discharge to occur" or on "high risk patient and/or family issues requiring early treatment planning and immediate intervention" or on "specific community resources/support systems for utilization in discharge planning."

Based on record review and interview, the facility failed to ensure that Activity Therapy Assessments were implemented for six (6) of six (6) active sample patients (A3, A4, A5, A11, A13 and A14). Despite the fact that all patients were expected to participate in all activity groups offered on the unit, no activity assessments were done. This failure results in activity therapy staff providing groups not based on assessed needs of each patient, making it difficult to provide specific individual focus for each patient in the group.

Findings include:

A. Record Review

None of the following six (6) active sample patients (date of Master Treatment Plan in parenthesis) included specific activities on the Master Treatment Plan: A3 (1/7/15), A4 (1/7/15), A5 (1/9/15), A11 (1/12/15), A13 (1/12/15), and A14 (1/12/15). The OT/TA intervention was generic and the same on each patient's plan. The intervention was: "Participation in daily OT/TA indoor programming." Focuses were: (1) "Daily goals group and wrap up to: "[area left blank]. (2) "OT/TA groups to assist in developing living skills, coping skills and leisure skill." Frequency - Daily."

B. Interview

In an interview on 1/13/15 at 1:00 p.m. with the Director of Activity Therapy, she was asked if the activity therapy staff's groups were considered "Leisure" or "Therapeutic." The Director stated that all the groups were therapeutic. When she was asked how the therapist obtained information on each patient, the Director replied "They read the patient's chart." She acknowledged that no patient assessment was done on the patients, but stated she agreed they needed to be done.

Based on observations, interviews, review of personnel files, review of Infection Control (IC) quality indicators, and review of Hospital policies, on 1/12/15, 1/13/15, and 1/14/15, the Chief Executive Officer (CEO), Medical Director, and the Director of Nursing (DON) failed to ensure a Hospital-wide IC training program was developed and implemented and ensure the implementation of corrective action plans in affected problem areas. Findings include:

1. During interview on 1/13/15 at 10:45 A.M., the Infection Control Nurse (ICN) said that she conducted monthly hand hygiene audits on all clinical staff [physicians, nurses, mental health aides (MHA), and social workers (SW)]. However, the ICN said that she did not conduct hand hygiene audits of Housekeeping and Dietary staff. The ICN said she "was only involved with infection control (training and monitoring) for Department of Nursing staff."

The ICN said that she did not ensure personnel competency and compliance with job-specific IC policies through routine IC training of Housekeeping staff, although required by the Hospital Patient Safety Initiative Infection Control Tool.

The ICN said that she did not report any findings to the Quality Assessment Performance Improvement (QAPI) Committee.

2. During interview with the ICN on 1/13/15 at 10:45 A.M., the ICN said that although she reported hand hygiene monitoring and tuberculosis (TB) and flu vaccination data, she did not have documentation of development and implementation of corrective interventions for the above indicators that needed improvement, as required by the Patient Safety Initiative Infection Control Tool.