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I. Based on document review and interview, the facility failed to provide a complete psychiatric evaluation within 60 hours of admission for 3 of 8 active sample patients (C2, C3 and C4). This failure can result in the treatment team not having enough input from the attending physician for the development of a comprehensive treatment plan. (Refer to B111)

II. Based on record review and staff interviews, the facility failed to develop a comprehensive treatment plan that included identified acute medical problems for 1 of 8 active sample patients (C1). The patient needed transfer to a community emergency department for stabilization of ongoing medical illnesses. The medical problems had not been included in the Master Treatment Plan. Failure to include acute medical problems as part of the treatment plan places patients at risk for exacerbation of medical problems. (Refer to B118-I)

III. Based on observation, record review, policy review and interviews, the facility failed to ensure that Master Treatment Plans of 4 of 4 active sample patients who had been in the facility longer than one week (C1, C2, C3 and C4) were adequately developed and reviewed/updated by the interdisciplinary team. Failure to provide comprehensive treatment plans for patients, with reviews/updates on a regular basis, hampers the staff's ability to document patient progress for identified problems, potentially leaving problems unresolved at the time of discharge. (Refer to B118-II)

IV. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included an inventory of the patient's strengths for 4 of 4 active sample patients who had been in the hospital long enough for the master treatment plan to be completed (C1, C2, C3 and C4). This failure hampers the staff's ability to determine how patient strengths can be utilized in treatment. (Refer to B119)

V. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included substantiated diagnoses based on input from the treatment team for 4 of 4 sample patients who had been in the hospital long enough for a Master Treatment Plan to be completed (C1, C2, C3 and C4). The plans were missing both psychiatric and medical substantiated diagnoses. This failure results in MTP's which cannot provide adequate guidance for patient care. (Refer to B120)

VI. Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified short term (ST) and long term (LT) goals stated in observable, measurable, behavioral terms for 4 of 4 active sample patients who had been in the hospital long enough to for a Master Treatment Plan to be completed (C1, C2, C3 and C4). This failure results in patients not having treatment goals which are individualized, measurable, or based on desired patient outcomes. (Refer to B121)

VII. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for 4 of 4 active sample patients who had been hospitalized long enough to have MTPs completed (C1, C2, C3 and C4) included physician, recreation therapy and occupation therapy interventions. Social Work interventions were missing on the MTP for 1 of the 4 patients (C1) and were generic tasks for the other 3 patients (C2, C3 and C4). Nursing interventions also were stated as generic tasks. The listed interventions also did not specify the focus of the individual and/or group modalities for the patients or list the frequency of the sessions. These deficiencies show a lack of integrated and comprehensive multidisciplinary treatment planning, and result in treatment plans that do not adequately specify individualized interventions for active treatment. (Refer to B122)

VIII. Based on record review and interviews, the facility failed to ensure proper documentation of patient records. Review of treatment plan sheets revealed that staff members, including the Medical Director, amended the Master Treatment Plans of four of four plans reviewed (C1, C2, C3 and C4) without properly dating the amendments. Failure to properly document patient records results in documents that do not accurately reflect the activities of staff related to patient care. (Refer to B125)

IX. Based on observation, record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient's response (or non-response) to treatment for 1 of 2 active sample patients who were transferred to the community hospital emergency department for acute medical care (C1). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient in an emergency setting. (Refer to B133-I)

I. Based on document review and interview, the facility failed to employ a medical physician for an adequate number of hours to provide direct patient care, treatment team participation and supervision of allied health professionals. The facility utilized a single primary care physician on a part time basis as a Consultant and for once-a-month weekend coverage. The physician was not available for the direct in house supervision of an active patient (C1) who had experienced an exacerbation of cardiac problems, necessitating emergency transfer to a community hospital emergency department for evaluation. The failure to provide sufficient medical supervision by a physician places patients at risk for increased complications of medical conditions. (Refer to B138)

II. Based on record review and interview, the Medical Director failed to ensure that Admission History and Physical Examinations were countersigned by a physician in a timely manner for 4 of 8 active sample patients who had examinations performed by an allied health professional. This failure of oversight places patients at risk of not having a medical diagnosis confirmed by a physician prior to initiating treatment. (Refer to B144-I)

III. Based on death record reviews and interviews, the Medical Director failed to develop an adequate method of evaluating and documenting death reviews for 3 of 3 death records reviewed (X1, X2, and X3). This failure hinders the development of action plans to address possible areas of deficiency related to deaths at the facility. (Refer to B144-II)

IV. Based on record review and staff interview, it was determined that the Director of Nursing had insufficient education and experience for her current administrative position as Nurse Executive in the facility. This deficient practice can result in lack of quality nursing care for the patients. (Refer to B147)

V. Based on document review and interviews, the facility failed to provide or have available psychological services. This omission compromises the facility's ability to address all of the patient's problems and needs in a timely manner. (Refer to B151)

VI. Based on document review and interview, it was determined that there was no evidence that the Director of Social Services monitored the services provided by the social work staff. Without monitoring, there is potential for major gaps in social services for patients. (Refer to B152)

VII. Based on document review and interview, the facility failed to provide a Director of Social Work who possessed a Master's degree in social work. There was a part time Master's prepared social worker on staff, yet there was no evidence of any peer review process or supervision. This failure can lead to less than optimal social services being provided to patients. (Refer to B154)

Based on record review and interview, the facility failed to provide social work assessment updates that included conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for 2 of 2 active sample patients readmitted to the facility (C3 and S1). This failure potentially results in a lack of professional social work treatment service and/or lack of social work input to the treatment team.

Findings include:

A. Record Review

1. Patient C3 was readmitted to the facility on 5/25/12. The medical record included a Social History from an admission on 12/23/10 and a Social History Update dated 5/26/12. The update failed to include any conclusions or recommendations for social work intervention for the current admission.

2. Patient S1 was readmitted to the facility on 6/8/12. The medical record included a Social History Update which was undated and unsigned. The update failed to include any conclusions or recommendations for social work intervention during the current admission. No Social History was present in the record from a previous admission.

B. Interview

In an interview on 6/13/12 at 11a.m., when shown the medical records for Patient C3 and Patient S1, the Director of Social Services stated, "We don't really have a policy about how and when to do updates." The Director of Social Services acknowledged that the two updates did not include recommendations or conclusions.

Based on document review and interview, the facility failed to provide a complete psychiatric evaluation within 60 hours of admission for 3 of 8 active sample patients (C2, C3 and C4). This failure can result in the treatment team not having enough input from the attending physician for development of a comprehensive treatment plan.

Findings include:

A. Document Review

1. Facility Medical Staff Bylaws, Section 3.6 states, "The complete history and psychiatric examination shall, in all cases, be completed within twenty-four (24) hours following admission of the patient."

2. Patient C2, admitted on 5/25/12, had an Inpatient Psychiatric Evaluation performed and signed by a physician's assistant on 5/25/12. The attending psychiatrist did not sign the evaluation until 6/4/12.

3. Patient C3, admitted on 5/25/12, had an Inpatient Psychiatric Evaluation performed and signed by a physician's assistant on 5/25/12. The attending psychiatrist did not sign the evaluation until 6/4/12.

4. Patient C4, admitted on 5/27/12, had an Inpatient Psychiatric Evaluation performed and signed by a physician's assistant on 5/28/12. The attending psychiatrist did not sign the evaluation until 6/4/12.

B. Interview

In an interview on 6/12/12 at 3:45p.m., the Medical Director was asked about the timeframes for completion of evaluations. She stated that the evaluation is not considered complete by the facility's standards until the attending psychiatrist signs off on the evaluations. She also stated that she doesn't always sign off right away (within 24 hours) "because I may be away on vacation and don't get around to it. The other psychiatrist covering for me hasn't been asked to supervise the work of the allied health people when I'm gone."

Based on record review and interview, the facility failed to list patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 3 of 8 active sample patients (C2, C3 and C4). This failure hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths.

Findings include:

A. Record Review

1. Patient C2: In an Inpatient Psychiatric Evaluation dated 5/25/12, assets were noted as "average intelligence." It was difficult to ascertain the descriptive nature of such an asset from the brevity of the statement.

2. Patient C3: In an Inpatient Psychiatric Evaluation dated 5/25/12, assets were noted as "in a skilled nursing facility as a place of residence." It was difficult to determine how this asset would be helpful for development of the patient's master treatment plan.

3. Patient C4: In an Inpatient Psychiatric Evaluation dated 5/28/12, assets were noted as "average intelligence." It was difficult to ascertain the descriptive nature of such an asset from the brevity of the statement.

B. Interview

In an interview on 6/12/12 at 3:45p.m., when shown the three evaluations noted above, the Medical Director agreed with the findings and stated, "I don't consider this adequate."

I. Based on record review and staff interviews, the facility failed to develop a comprehensive treatment plan that included identified acute medical problems for 1 of 8 active sample patients (C1). The patient needed transfer to a community emergency department for stabilization of ongoing medical illnesses. The medical problems had not been included in the treatment plan. Failure to include acute medical problems as part of the Master Treatment Plan places patients at risk for exacerbation of medical problems.

Findings include:

A. Record Review

1. Patient C1, an older adult, was admitted to the facility on 6/2/12 for depression and alcohol use. In an Admission History and Physical Examination 6/2/12, the physician noted that the patient had a history of cardiac arrhythmia and had a heart attack and stroke in December 2011. The physician recommended in the Plan section of the History and Physical that a Digoxin level be obtained. He stated that he would speak to the patient's cardiologist about medication management. The physician noted that a "Dig (digoxin) level was added to the admission labs." Hospital staff was unable to locate the results of the Digoxin level. There were no physician progress notes to indicate that follow up examinations/phone calls had been performed for Patient C1 as recommended.

2. Patient C1's Master Treatment Plan dated 6/2/12 noted the following problems: "#1: Fall Risk, #2: Depressed Mood; #3: Discharge Planning." There was no mention of acute medical problems in the plan. There also was no evidence that primary care staff attended the treatment team meeting.

3. On the afternoon of 6/11/12, Patient C1 developed chest pain. Paramedics were called to the facility, and the patient was transported to the local community hospital emergency department for evaluation.

B. Interviews

1. In an interview on 6/12/11 at 2:30p.m., the Director of Nursing (who is also the Director of Quality Improvement) acknowledged that the treatment team failed to address medical problems when Patient C1's treatment plan was developed.

2. In an interview on 6/12/11 at 3:30p.m., the Medical Director agreed with the findings noted above and stated, "This (medical problem) should have been part of the treatment plan and could have been watched closer." The Medical Director also stated, "[Primary care physician] doesn't attend treatment team meetings to discuss medical problems."

II. Based on observation, record review, policy review and interviews, the facility failed to ensure that Master Treatment Plans of 4 of 4 active sample patients who had been in the facility longer than one week (C1, C2, C3 and C4) were adequately developed and reviewed/updated by the interdisciplinary team. Failure to provide comprehensive treatment plans for patients, with reviews/updates on a regular basis, hampers the staff's ability to document patient progress for identified problems, potentially leaving acute problems unresolved at the time of discharge.

Findings include:

A. Observations

An observation of a treatment team meeting on 6/11/12 between 11a.m. and 12p.m., revealed a staff discussion of each patient ' s current status (patient rounds). At no time did a treatment team staff member attending the meeting (charge nurse, Medical Director, Director of Social Work and Program Director) open up a patient chart to look at the treatment plan. It was unclear how the discussion in the treatment team meeting reflected the patient's Master Treatment Plans, or how the interdisciplinary team members planned to review/update the written plans.

B. Policy Review

The facility Policy titled "Updating the ICTP (Interdisciplinary Comprehensive Treatment Plan), dated 1/31/2012, includes the following statement: "Procedure: 1. Each week the Treatment Team will meet and review each ICTP."

C. Record Review

1.The facility's treatment planning documents included standardized preprinted forms for potential problems (e.g., Depression, Anxiety, Confusion, or Fall risk) that could be selected by staff (by checking boxes on the forms) for each patient, and another form for discharge planning. There were preprinted goals and interventions for each identified problem and for discharge planning, in addition to lines or blank spaces which staff could use to write in comments to individualize the plan for each patient and update the plan. Each discipline was expected to check the appropriate boxes under their discipline on the plan when their assessments were completed. However, there was no mechanism to indicate when each 'section' was completed by each discipline, so it was unclear if they were completed after the assessments. There also was only one date on the written plan -- the date the plan was initiated by nursing which often was the admission date.

2. Specific patient findings:

a. Patient C1, admitted 6/2/12, had a Master Treatment Plan dated 6/2/12 with problems listed on 3 separate preprinted forms, and with preprinted goals and interventions. The selected problems were Fall Risk, Depressed Mood, and Discharge Planning. As of the last day of the survey (6/13/12), the MTPs were missing some discipline interventions (see details at B122) and the plan forms had blank areas on the back page where the weekly updates were to be filled in when the treatment team meets.

2. Patient C2, admitted 5/25/12, had a Master Treatment Plan dated 5/26/12 with problems listed on 3 separate preprinted forms, and with preprinted goals and interventions. The selected problems were Confusion, Anxiety, and Discharge Planning. As of the last day of the survey (6/13/12), the MTPs were missing some discipline interventions (see details at B122) and the plan forms had blank areas on the back page where the weekly updates were supposed to be filled in when the treatment team meets.

3. Patient C3, admitted 5/25/ 12, had a Master Treatment Plan dated 5/26/12 with problems listed on 3 separate preprinted forms, with preprinted goals and interventions. The selected problems were Fall Risk, Depressed Mood, and Discharge Planning. As of the last day of the survey (6/13/12), the MTPs were missing some discipline interventions (see details at B122) and the plan forms had blank areas on the back page where the weekly updates were supposed to be filled in when the treatment team meets.

4. Patient C4, admitted 5/27/12, had a Master Treatment Plan dated 5/27/12 with problems listed on 4 separate preprinted forms, with preprinted goals and interventions. The selected problems were Confusion, Fall Risk, Depressed Mood, and Discharge Planning. As of the last day of the survey (6/13/12), the MTPs were missing some discipline interventions (see details at B122) and the plan forms had blank areas on the back page where the weekly updates were supposed to be filled in when the treatment team meets.

D. Interviews

1. In an interview on 6/12/12 at 2:30p.m., the Director of Nursing (who is also the Director of Quality Improvement) stated that treatment team updates occur on a daily basis and that the treatment plans should be updated. When shown examples of the Master Treatment Plans noted above, the Director of Nursing agreed that treatment plan updates are not being completed and documented.

2. In an interview on 6/12/12 at 3:45p.m., the Medical Director was shown examples of the treatment plans noted above; she stated that she had not been completing the forms during the meetings. The Medical Director also stated, "I don't like this written form at all."

3. In an interview on 6/13/12 at 10:45a.m., the Director of Social Services agreed with the findings above and stated, "We haven't been updating the forms on a regular basis."

III. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) included an inventory of the patient's strengths for 4 of 4 active sample patients (C1, C2, C3 and C4) who had been in the hospital long enough to have a Master Treatment Plan completed. This failure hampers staff's ability to determine how patient strengths can be utilized in treatment. (Refer to B119)

IV. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included substantiated diagnoses based on input from the treatment team for 4 of 4 sample patients (C1, C2, C3 and C4) who had been in the hospital long enough to have master treatment plans completed. The plans were missing both psychiatric and medical substantiated diagnoses. This failure results in MTP's which cannot provide adequate guidance for patient care. (Refer to B120)

V. Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans (MTP) that identified short term (ST) and long term (LT) goals stated in observable, measurable, behavioral terms for 4 of 4 active sample patients (C1, C2, C3 and C4) who had been in the hospital long enough to have a Master Treatment Plan completed. This failure results in patients not having treatment goals which are individualized, measurable or based on desired patient outcomes. (Refer to B121)

VI. Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for 4 of 4 active sample patients who had been hospitalized long enough to have MTPs completed (C1, C2, C3 and C4) included physician, recreation therapy and occupation therapy interventions. Social Work interventions were missing on the MTP for 1 of the 4 patients (C1) and were generic tasks for the other 3 patients (C2, C3 and C4). Nursing interventions also were stated as generic tasks. The listed interventions also did not specify the focus of the individual and/or group modalities for the patients or list the frequency of the sessions. These deficiencies show a lack of integrated and comprehensive multidisciplinary treatment planning, and result in treatment plans that do not adequately specify individualized interventions for active treatment. (Refer to B122)

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) included an inventory of the patient's strengths for 4 of 4 active sample patients who had been in the hospital long enough to have Master Treatment Plans completed (C1, C2, C3 and C4). This failure hampers staff's ability to determine how patient strengths can be utilized in treatment.

Findings include:

A. Policy/Document Review

1. The facility policy titled "Interdisciplinary Comprehensive Treatment Plan (ICTP), Comprehensive", dated 1/31/12, includes the following statements: "A. patient's strengths and limitations will be considered in the ICTP." 5c.: "The ICTP is designed to: c. Build on the patient's strengths..." The facility refers to the MTP as the ICTP which includes "care plans" related to the identified problems.

B. Record Review

1. Patient C1 (admitted 6/2/12). In the MTP (ICTP) of 6/2/12 (no updated MTP), there were no assets documented.

2. Patient C2 (admitted 5/25/12). In the MTP (ICTP) of 5/26/12 (no updated MTP), there were no assets documented.

3. Patient C3 (admitted 5/25/12). In the MTP (ICTP) of 5/26/12 (no updated MTP), there were no assets documented.

4. Patient C4 (admitted 5/27/12). In the MTP (ICTP) of 5/27/12 (no updated MTP), there were no assets documented.

C. Staff Interviews

1. In an interview on 6/12/12 at 4p.m., after reviewing the treatment plans for patients C1 and C2, the Medical Director agreed that the MTPs did not document patient strengths/assets. She also acknowledged the physician's responsibility (as leader of the treatment team) for ensuring complete MTP's.

2. In an interview on 6/12/12 at 3p.m., after reviewing the treatment plans for patients C1 and C2, the Director of Nursing (DON) acknowledged that the plans did not include patient strengths/assets that had been identified in the assessments.

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plan (MTP) included substantiated diagnoses based on input from the treatment team for 4 of 4 sample patients who had been in the hospital long enough to have a master treatment plan completed (C1, C2, C3 and C4). Both psychiatric and medical substantiated diagnoses were missing from the plans. This failure results in MTP's which cannot provide adequate guidance for patient care.

Findings include:

A. Policy/Document Review

1. The facility policy titled "Interdisciplinary Comprehensive Treatment Plan (ICTP), Comprehensive", dated 1/31/12, includes the following statements in the "Introduction" section: "Policy: The interdisciplinary team will develop a comprehensive, patient specific ICTP". "Procedure 2" states, "The preliminary care plan and ICTP will be developed by the admitting RN and the interdisciplinary team and will follow guidelines of the physician's orders. It may include care planning for: a. Active medical issues; b. Psychosocial issues; c. Treatment goals; d. Treatment plans; and e. Effectiveness and outcome of medical treatment."

The facility policy "ICTP" includes the following statements in the "Comprehensive" section, "Procedure 7": "The ICTP will focus on the identified diagnoses and target behaviors present at admission. The ICTP will focus on providing the best functional outcomes that can be anticipated. Interventions and treatment goals will be derived by reviewing the patient's strength's [sic] and limitations, history and physical, psychiatric evaluation, past medical history, clinical exams, lab values, and patient interviews; and it will address the strengths and disabilities of the patient. Other variables affecting patient care will also be considered." The facility refers to the MTP as the ICTP which include "care plans" related to the identified problems.

B. Record Review

1. Patient C1 (admitted 6/2/12) The MTP (ICTP) of 6/2/12 (no MTP update) included no substantiated diagnoses.

2. Patient C2 (admitted 5/25/12). The MTP (ICTP) of 5/26/12 (no MTP update) included no substantiated diagnoses.

3. Patient C3 (admitted 5/25/12). The MTP (ICTP) of 5/26/12 (no MTP update) included no substantiated diagnoses.

4. Patient C4 (admitted 5/27/12). The MTP (ECTP) of 5/27/12 (no MTP update) included no substantiated diagnoses.

C. Staff Interviews

1. In an interview on 6/12/12 at 4p.m., after reviewing the treatment plans for patients C1 and C2, the Medical Director agreed that the MTPs did not document any substantiated diagnosis.

2. In an interview on 6/12/12 at 3p.m., after reviewing the treatment plans for patients C1 and C2, the Director of Nursing (DON) acknowledged that the plans did not include substantiated diagnoses that had been identified by the psychiatrist and medical physician during the assessments.

Based on policy review, record review and interview, the facility failed to provide Master Treatment Plans (MTP) that identified short term (ST) and long term (LT) goals stated in observable, measurable, behavioral terms for 4 of 4 active sample patients who had been in the hospital long enough to have a Master Treatment Plan completed (C1, C2, C3, and C4). This failure results in patients not having treatment goals which are individualized, measurable, and based on desired patient outcomes. Lack of measurable, patient specific short term goals hampers the treatment team's ability to measure change in the patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to patient needs.

Findings include:

A. Policy Review

The facility policy titled "Interdisciplinary Comprehensive Treatment Plan (ICTP), Goals and Objectives," dated 1/31/12, includes the following statements: "Policy: ICTP's shall incorporate short and long term goals and objectives, which help promote the patient's highest obtainable level of independence and functioning. Procedure: 1. Goals and objectives are defined as the desired outcome for a specific problem. 2. Goals and objectives will be: a. Patient oriented; b. Behaviorally oriented; c. Measurable; and d. Within a specified time frame."

B. Record Review

1. Review of the 4 sample patient's MTPs revealed preprinted goals for selected problems (e.g., Fall Risk; Confusion; Depressed Mood; Anxiety; Discharge Planning). Most of the goals focused on compliance with treatment (staff expectations for patients' participation in treatment) and were very similar or identical for all patients with the same listed problems. For example, the long term goal for discharge planning was a generic statement that was the same for all patients. In addition, many of the listed goals were not measurable patient outcome behaviors.

2. Specific Patient Findings:

a. Patient C1 (admitted 6/2/12, MTP 6/2/12).

"Problem #1: Fall risk" -- "ST goal: Pt will comply with plan of care throughout admission." (compliance focus)

"Problem #2: Depressed mood" -- "LT goal: Pt. will experience coping skills and improved mood upon discharge." (not measurable); "ST goal: Pt. will attend at least 3 group sessions regarding skills per week." (compliance focus)

"Problem#3: Discharge planning" -- "LT goal: Pt. will discharge to safe environment with adequate support system." (not measurable); "ST goal: The client will be able to be redirected and accept realty based affirmations. The client will be able to comply with the treatment therapy provided by this facility. The patient/person in charge of care will be involved in the plan of care and discharge planning." (compliance focus)

b. Patient C2 (admitted 5/25/12; MTP 5/26/12).

"Problem#1: Confusion" -- "LT goal: Pt. will have increased orientation and awareness of situations upon discharge" (not measurable); "ST goal: Pt will participate in at least one orientation building activity per day." (compliance focus)

"Problem #2: Anxiety" -- "LT goal: Pt. will have decreased episodes of anxiety r/t (related to) paranoia upon discharge" (not measurable); "ST goal: Pt. will participate with group sessions r/t (related to) coping skills at least 3 times/week." (compliance focus)

"Problem #3 Discharge planning" -- "LT goal: Pt. will discharge to safe environment with adequate support system" (generic; not measurable); "ST goal: Pt. will participate with discharge planning to best of (his/her) ability." (compliance focus)

c. Patient C3 (admitted 5/25/12; MTP 5/26/12)

"Problem #1: Depressed mood" - "LT goal: Pt will have decreased depressive mood and increased coping skills upon discharge" (not measurable); "ST goal: Pt. will attend group sessions regarding coping skills 3 times/week." (compliance focus)

"Problem #2: Fall risk" - "ST goal: Pt. will comply with safety care plan and staffing r/t related to) falls." (compliance focus)

"Problem #3 Discharge planning" - "LT goal: Pt. will discharge to safe environment with adequate support system" (not measurable); "ST goal: Pt. will participate with discharge planning to the best of (his/her) ability." (compliance focus)

d. Patient C4 (admitted 5/27/12; MTP 5/27/12).

"Problem #1: Confusion" - "LT goal: Pt. will exhibit decreased confusion and increased alert thoughts at time of discharge." (not measurable)
"Problem #2: Depressed mood" - "LT goal: Pt. will have decreased sx (symptoms) noted above at time of D.C. (discharge)." (not measurable)

"Problem #4: Discharge Planning" - "LT goal: Pt. will dc (discharge) to safe environment." (generic; not measurable).

There were no ST goals for the above problems on this patient's treatment plan. The "start, target date, renewal date, resolved date" sections for the LT goals also were blank.

B. Interviews

1. In an interview on 6/12/12 at 3p.m., after reviewing the treatment plans (with specific focus on fall risk and discharge planning goals), the Nursing Director acknowledged that the goals were generic and not measurable. The DON also noted that some ST goals were not documented (the form was blank in the section for ST goals for one patient (C4).

2. In an interview on 6/12/12 at 4p.m., the Medical Director acknowledged that the LT and ST goals in treatment plans for sample patients C1, C2, C3 and C4 were generic tasks, not individualized goals, and that the stated goals focused on "complying" with treatment rather than specifying observable patient outcomes. The Medical Director also acknowledged that there were no ST goals for one pt (C4). She agreed that goals needed to be stated in observable, measureable and behavioral terms and stated, "I don't like those plans, they are not good."

Based on policy review, record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) for 4 of 4 active sample patients who had been hospitalized long enough to have MTPs completed (C1, C2, C3 and C4) included physician, recreation therapy and occupation therapy interventions. Social Work interventions were missing on the MTP for 1 of the 4 patients (C1) and were generic tasks for the other 3 patients (C2, C3 and C4). Nursing interventions also were stated as generic tasks. The listed interventions also did not specify the focus of the individual and/or group modalities for the patients or list the frequency of the sessions. These deficiencies show a lack of integrated and comprehensive multidisciplinary treatment planning, and result in treatment plans that do not adequately specify individualized interventions for active treatment.

Findings include:

A. Policy Review

The facility policy entitled "Interdisciplinary Comprehensive Treatment Plan (ICTP), Comprehensive", dated 1/31/12, includes the following statements: "Procedure 7: Interventions and treatment goals will be derived by reviewing the patient's strength's and limitations, history and physical, psychiatric evaluation, past medical history, clinical exams, lab values, and patient interviews; it will address strengths and disabilities of the patient. Other variables affecting patient care will also be considered." The facility policy entitled "ICTP, Updating the ICTP", dated 1/31/12, also includes the following statement: Procedure 3, Each problem on the ICTP will be monitored for appropriate interventions and goals which may be changed as necessary to better reflect the patient's progress toward stated goals."

B. Record Review

1.The MTP's were documented on pre-printed treatment plan forms that included lists of generic interventions for the disciplines, with check boxes to select interventions and lines to add comments or to individualize the plans. The interventions were generic, with the same or very similar interventions listed on the plans for all patients having the same identified problems (e.g., fall risk, depressed mood, confusion, and anxiety) and for discharge planning.

2. Patient C1 (admitted 6/2/12; MTP 6/2/12).

a. Review of the patient's MTP showed that the check boxes to be used to select interventions by the physician, social worker, RT (recreational therapy), and OT (occupational therapy) were all left blank.

b. For "Problem #1: Fall risk. Nursing interventions were: "Place on fall precautions, monitor and document in pt. chart. Obtain orthostatic blood pressure as ordered by MD and PRN. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall prevention x1, reinforce as needed." These interventions were generic tasks (the same interventions listed on the plan for fall risk for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

c. For "Problem #2: Depressed mood." The nursing interventions were: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping & participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in ___ (line for patient input left blank). One-on-one to allow pt. to express feelings, use silence and active listening, document pt.'s response." These interventions were generic tasks (the same interventions listed on the plan for depressed mood for all patients who had this identified problem), with no comments on the blank lines to individualized the plan for this patients. Some of the interventions (e.g., medication monitoring) were standard care that would be expected to be provided for all patients in a hospital.

d. For "Problem#3: Discharge planning." The nursing interventions were: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt., just prior to discharge, provide copy of discharge planning to pt." These interventions were generic tasks (the same interventions listed on the plan for discharge planning for all patients), with no comments on the blank lines to individualize the plan for this patient.

2. Patient C2 (admitted 5/25/12; MTP 5/26/12).

a. Review of the patient's MTP showed that the check boxes to be used to select interventions by the physician, RT (recreational therapy), and OT (occupational therapy) were left blank.

b. For "Problem#1: Confusion," the nursing interventions were: "Assess level of confusion/disorientation each shift. Monitor the need for assistance each shift & encourage independence. Give clear, simple explanations and allow time for pt. to complete task, document pt. response. Assist pt. daily with personal hygien [sic] when pt. unable to complete, document pt. response." These interventions were generic tasks (the same interventions listed on the plan for confusion for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Provide group for process, education and daily support. Coordinated [sic] discharge planning, aftercare and community resources with the pt., pt. to document in journal." These interventions were generic tasks (the same interventions listed on the plan for confusion for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

c. For "Problem #2: Anxiety," the nursing interventions were: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and state side effects, document in the chart and report to MD. Offer PRN medications ordered by the MD to help with anxiety. Assist pt. to identify early signs to anxiety to develop interventions to assist pt. during these times. Have pt. document in ___ (line for patient input left blank). Encourage pt. to participate in daily activities and groups, provide positive feedback for accomplishments. Assist pt. to practice relaxation techniques when experiencing anxiety." These interventions were generic tasks (the same interventions listed on the plan for anxiety for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Educated [sic] on preventing relapse, identifying consequences, and to maintain sobriety during hospital stay. Family meetings/contact to educated family on co-dependency issues, diagnosis, community resources, and discharge needs. Pt. to attend AA/NA meetings on the unit each week." These social work interventions were generic tasks (the same interventions listed on the plan for anxiety for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

d. For "Problem #3: Discharge planning," the nursing interventions were: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt. just prior to discharge, provide a copy of discharge planning to pt." These nursing interventions were generic tasks (the same interventions listed on the plan for discharge planning for all patients), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Family meetings &/or contact for support & education regarding diagnosis, discharge needs, & community resources. Schedule appointments for pt. follow-up counseling & medication management." These social work interventions were generic tasks (the same interventions listed on the plan for discharge planning for all patients), with no comments on the blank lines to individualize the plan for this patient.

3. Patient C3 (admitted 5/25/12; MTP 5/26/12).

a. Review of Patient C3's MTP showed that the check boxes to be used to select interventions by the physician, RT (recreational therapy), and OT (occupational therapy) were left blank.

b. For "Problem #1: Depressed mood," the nursing interventions were: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping and participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in her journaling." These nursing interventions were generic tasks (the same interventions listed on the plan for depressed mood for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "See pt. individually for support & education regarding depression, encourage expression of feelings and document in journal. Groups for education, process with use of cognitive therapy, & support related to depression during hospital stay. Teach assertiveness skills in group and/ or 1:1 as needed. Meet or contact family for support & education regarding diagnosis, current stressors, losses, recovery, & relapse prevention. Assist pt. & family with discharge needs & community resources." These social work interventions were generic tasks (the same interventions listed on the plan for depressed mood for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

c. For "Problem #2: Fall risk," the nursing interventions were: "Place on fall precautions, monitor and document in the pt. chart. Obtain orthostatic blood pressure as ordered by MD and PRN. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related to ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall prevention x1, reinforce as needed." These nursing interventions were generic tasks (the same interventions listed on the plan for fall risk for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Assess for higher level of care upon discharge. Assess resources available for pt. after discharge, assist pt. to complete a list of resources and document." These social work interventions were generic tasks (the same interventions listed on the plan for fall risk for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

d. For "Problem #3 Discharge planning," the nursing interventions were: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow up appointments with the pt. just prior to discharge, provide copy of discharge planning to pt." These nursing interventions were generic tasks (the same interventions listed on the plan for discharge planning for all patients), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Family meetings &/or contact for support & education regarding diagnosis, discharge needs, & community resources. Schedule appointments for pt. follow-up counseling and medication management." These social work interventions were generic tasks (the same interventions listed on the plan for discharge planning for all patients), with no comments on the blank lines to individualize the plan for this patient.

4. Patient C4 (admitted 5/27/12, MTP 5/27/12).

a. Review of patient C4's MTP showed the check boxes to be used to select interventions by the physician, RT (recreational therapy), and OT (occupational therapy) were left blank.

b. For "Problem #1: Confusion," the nursing interventions were: "Assess level of confusion/ disorientation each shift. Monitor the need for assistance each shift & encourage independence. Give clear, simple explanations and allow time for pt. to complete task, document pt. response. Assist pt. with personal hygien [sic] when pt. unable to complete, document pt. response." These nursing interventions were generic tasks (the same interventions listed on the plan for confusion for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Med [sic] or contact family x 2 for education related to diagnosis, behavior management, discharge needs & community resources. Provide group for process, education, and support daily. Coordinated [sic] discharge placement, aftercare and community resources with the pt, pt. to document in ___ (line for patient input left blank)." These social work interventions were generic tasks (the same interventions listed on the plan for confusion for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

c. For "Problem #2: Depressed mood, "the nursing interventions were: "Monitor medications effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping and participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in ___ (line for patient input left blank). One-on-one allow pt. to express feelings, use silence and active listening, document pt. response." These nursing interventions were generic tasks (the same interventions listed on the plan for depressed mood for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "See pt. individually for support and education regarding depression, encourage expression of feelings. Groups for education, process with use of cognitive therapy, and support related to depression during hospital stay. Teach assertiveness skills in group and/or 1:1 as needed. Meet or contact family for support and education regarding diagnosis, current stressors, losses, recovery, and relapse prevention. Assist pt. and family with discharge needs and community resources." The social work interventions were generic tasks (the same interventions listed on the plan for depressed mood for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

d. For "Problem #3: Fall risk," nursing interventions were: "Place on fall precautions, monitor and document in pt. chart. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related to ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall preventionx1, reinforce as needed. "These nursing interventions were generic tasks (the same interventions listed on the plan for fall risk for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

Social Worker interventions were: "Assess for higher level of care upon discharge. Assess resources available for pt. after discharge, assist pt. to complete a list of resources and document." These social work interventions were generic tasks (the same interventions listed on the plan for fall risk for all patients who had this identified problem), with no comments on the blank lines to individualize the plan for this patient.

e. For "Problem #4: Discharge Planning," nursing interventions were: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt. just prior to discharge, provide copy of discharge planning to pt." These nursing interventions were generic (the same interventions listed on the plan for all patients related to discharge planning), with no comments on the blank lines to individualize the plan for this patient.

B. Interviews

1. In an interview on 6/12/12 at 4p.m., after reviewing the treatment plans for patients C1 and C2, the Medical Director agreed that the interventions documented on the MTPs were selected from a generic check box form, and no comments were added on the lines to individualize the plans. She also acknowledged the physician's responsibility (as leader of the treatment team) for ensuring complete MTP's.

2. In an interview on 6/12/12 at 3p.m., after reviewing the treatment plans for patients C1 and C2, the Director of Nursing (DON) acknowledged that interventions were selected from a generic check box form, and that the listed nursing interventions were standard functions expected for nursing care, and did not specify therapeutic group modalities and frequency related to the patient schedules/program delivery.

3. In an interview on 6/13/11 at 11a.m., after reviewing the treatment plans for patients C1 and C2, the Director of Social Work (SW) acknowledged that the interventions were documented using a generic check box form, and that the listed social work interventions were generic functions expected of the social worker and did not specify therapeutic group modalities and frequency related to the patient schedules/ program delivery. The SW Director stated that she has been responsible for "all SW functions, which is a lot", including "groups (weekdays and weekends), evaluations, intake calls (during her work hours), family meetings, treatment team meetings." She said that a new SW had started in orientation this week "which should help."

Based on record review and interviews, the facility failed to ensure proper documentation of patient records. Review of treatment plan sheets revealed that staff members, including the Medical Director, amended the Master Treatment Plans of four of four plans reviewed (C1, C2, C3 and C4) without properly dating the amendments. Failure to properly document patient records results in documents that do not accurately reflect the activities of staff related to patient care.

Findings include:

A. Record Review (MTP dates in parentheses)

1. In a record review on 6/11/12 at 10:15a.m., the surveyor noted that all four Master Treatment Plans (MTP) reviewed: C1 (6/2/12), C2 (5/26/12), C3 (5/26/12) and C4 (5/27/12) were missing interventions for the physicians and the rehabilitation therapist. Physician signatures were also missing from the treatment plans. The treatment plans were photocopied at that time.

2. In a record review on 6/11/12 at 2p.m., the same treatment plans were noted as completed.

a. Patient C1 had a Master Treatment Plan that was dated 6/2/12. No other data entry dates were noted on the plan. The additions (added on 6/11/12) were located in the physician and RT (rehab therapist) intervention sections of the Master Treatment Plan.

b. Patient C2 had a Master Treatment Plan that was dated 5/26/12. No other data entry dates were noted on the plan. The additions (added on 6/11/12) were located in the physician and RT (rehab therapist) intervention sections of the Master Treatment Plan.

c. Patient C3 had a Master Treatment Plan that was dated 5/26/12. No other data entry dates were noted on the plan. The additions (added on 6/11/12) were located in the physician and RT (rehab therapist) intervention sections of the Master Treatment Plan.

d. Patient C4 had a Master Treatment Plan that was dated 5/27/12. No other data entry dates were noted on the plan. The additions (added on 6/11/12) were located in the physician and RT (rehab therapist) intervention sections of the Master Treatment Plan.

B. Interviews

1. In an interview on 6/11/12 at 3:15p.m. with the Chief Executive Officer and Program Director, the Program Director admitted to having filled in his sections of the treatment plans for all four patients, (C1, C2, C3 and C4) and not adding a date or time for the new addition of information.

2. In an interview on 6/12/12 at 9:30a.m., the Medical Director admitted that she had filled in the Master Treatment Plan for all four patients, (C1, C2, C3 and C4) without dating the new additions.

I. Based on observation, record review and interview, the facility failed to provide a discharge summary that summarized all the treatment received in the hospital and the patient ' s response (or non-response) to treatment for 1 of 2 active sample patients who were transferred to the community hospital emergency department for acute medical care (C1). The patient experienced a medical crisis; the discharge summary did not provide any information about the situation or any care that had been attempted to address the issue prior to transfer. This failure compromises the effective transfer of the patient's care to the next care provider by failing to provide information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

A. Observation

In an observation on 6/11/12 at approximately 3p.m., emergency medical service personnel arrived at the facility to evaluate Patient C1 for complaints of chest pain. Patient C1 was taken to the community hospital emergency department for evaluation.

B. Record Review

1. Patient C1's medical record did not contain a transfer note or discharge order when reviewed at intervals between 6/11/12 and 6/13/12.

2. In a discharge summary dated 6/11/12 at 4:11p.m., the nurse practitioner failed to note any information related to Patient C1's cardiac status or condition, any medication changes during the hospitalization, or any information related to the reason for transfer of the patient to an acute care hospital. Verbatim description under the section titled "Course in hospital" follows: "Patient was given a physical exam, a psychiatric evaluation, a psychosocial assessment and a nursing assessment. Patient was involved in group and individual therapy as well as the unit milieu therapy. A psychosocial assessment was done. A treatment plan was formulated. At the time of (C1) admission, (C1) continued with demanding behavior much of which is centered around Bingo which was scheduled at the SNF [skilled nursing facility] the following day. (C1) has called multiple to [sic] (his/her) room for minimal questions and tasks even when up in wheelchair (C1) has not felt as if the interaction with other patient was of benefit and became intrusive with staff that were attending other patients [sic]."

3. The Discharge Summary noted under the section titled "Condition on Discharge": "Unresponsive"; noted under the section titled "Prognosis": "poor."

C. Interview

In an interview on 6/12/12 at 3:45p.m., the Medical Director was shown the Discharge Summary for Patient C1. She agreed that the hospital course section of the discharge summary did not describe any information about the need to transfer the patient to an emergency room. She also agreed that the document failed to describe what treatments had been tried or changed to help address Patient C1 ' s medical issues.

II. Based on policy review, document review and interview, the facility failed to ensure that discharge summaries were signed by the attending physician within 15 days of discharge in 2 of 5 discharge records reviewed (D2 and D5). This deficiency results in discharge summaries that include the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan being sent out to outpatient providers prior to review by the attending physician.

Findings include:

A. Policy Review

Facility Policy titled "Medical Records" dated 1/31/2004 notes under the section titled "Policy" the following: "Discharge Summary's (sic) are to be completed within 15 days as stipulated in the facilities (sic) bylaws; Rules and Regulations, paragraph 4, section F."

B. Record Review

1. Patient D2: The Inpatient Psychiatric Discharge Summary dated 4/20/12 was not signed by the attending psychiatrist until 5/29/12. (24 days late)

2. Patient D5: The Inpatient Psychiatric Discharge Summary dated 4/27/12 was not signed by the attending psychiatrist until 5/29/12. (17 days late)

C. Interview

In an interview on 6/12/12 at 3:45p.m., the Medical Director reviewed the discharge summaries noted above and agreed with the findings that the signatures were late.

Based on record review and interview, the facility failed to ensure that the date and time for follow-up appointments were included in the discharge summaries of 5 of 5 discharge records reviewed (D1, D2, D3, D4 and D5). The lack of definite follow-up appointments forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices for follow-up, an action which they may find difficult to do, and therefore may fail to do.

Findings include:

A. Record Review

In all five reviewed Inpatient Psychiatric Discharge Summaries below, the following statement was noted under the section titled "Follow-up": "Within 30 days for Physical Medicine and Psychiatry." No other information was noted on any of the 5 records for follow-up appointments.

D1 discharged 4/5/12; discharge summary dictated 4/5/12
D2 discharged 4/20/12; discharge summary dictated 4/20/12
D3 discharged 5/7/12; discharge summary dictated 5/7/12
D4 discharged 5/1/12; discharge summary dictated 5/1/12
D5 discharged 4/27/12; discharge summary dictated 4/27/12

B. Interview

In an interview on 6/12/12 at 3:45p.m., the Medical Director reviewed the discharge summaries noted above and agreed with the findings that follow up appointments were not listed.

Based on observation, document review and interviews, the facility failed to deploy sufficient primary medical care providers to meet the acute medical needs of 1 of 2 active sample patients who had to be transferred to a community hospital emergency department for evaluation (C1). This failure was evidenced by the lack of medical specialist input into the master treatment plans for both patients, the lack of direct oversight of allied health professionals by the medical specialist by the lack of co-signatures for history and physical examinations performed by a physician's assistant and the lack of a physicians order for hospital transfer for one active sample patient (C1). The failure to utilize the expertise of a medical specialist for treatment team planning, allied health professional supervision and physician orders places patients at risk for increased medical illness complications.

Findings include:

A. Document Review

The Medical Executive Committee minutes dated 3/2012, were in verbatim transcript form. There was a discussion noted where the Medical Director was talking about the deployment of MD1 (primary care physician): "[MD1] is here on a limited basis and this is an issue." Prior to this statement, the Medical Director was quoted as saying that she wanted the Psychiatric Nurse Practitioner to supervise the Physician's Assistant, even though the governing board and bylaws do not allow such an arrangement. The Medical Director stated the following about MD1 "There is no financial provision for him to be the Physician Services Coordinator over here (acute psychiatric unit)."

CMS Form 729 - Medical Staff Coverage, completed by the facility on 6/12/12, indicated that the facility utilizes one Family Practice physician part-time and one Physician's Assistant part-time.

B. Interviews

1. In an interview on 6/11/12 at 2:45p.m., RN1 stated that the Primary Care physician is available by phone "when we need him, but they (the doctors) rely on us (nurses) to call them if there's a problem." RN1 also confirmed that the primary care providers do not attend treatment team meetings, and that MD1 did not come in to see Patient C1 prior to a transfer to a community hospital for emergency medical care.

2. In an interview on 6/12/12 at 11:30a.m., RN2 confirmed the information that RN1 had reported the day before about physician coverage.

3. In an interview on 6/12/12 at 3:45p.m., the Medical Director admitted that the facility did not have enough primary care coverage by a physician. She stated that the physician's assistant had been reassigned last week to work in the skilled nursing home portion of the facility and was only available as a "backup to the psychiatric nurse practitioner." The Medical Director described the primary care physician's duties as: "being available by phone twenty four hours a day, coming in on one weekend a month to cover admissions, but he has no set hours for direct care per se." The Medical director also stated, "We're just now learning how to do things here."

Based on document review and interview, the facility failed to employ a medical physician for an adequate number of hours to provide direct patient care, treatment team participation and supervision of allied health professionals. The facility utilized a single primary care physician on a part time basis as a Consultant and for once-a-month weekend coverage. The physician was not available for the direct in house supervision of active patient (C1) who had experienced an exacerbation of cardiac problems, necessitating emergency transfer to a community hospital emergency department for evaluation. The failure to provide enough medical supervision by a physician places patients at risk for increased complications of medical conditions.

Findings include:

A. Document Review

Medical Executive Committee minutes dated 3/2012, were in verbatim transcript form. There was a discussion noted where the Medical Director was talking about the deployment of MD1 (primary care physician); "[MD1] is here on a limited basis and this is an issue." Prior to this statement the Medical Director was quoted as saying that she wanted the Psychiatric Nurse Practitioner to supervise the Physician's Assistant, even though the governing board and bylaws do not allow such an arrangement. The Medical Director stated the following about MD1: "There is no financial provision for him to be the Physician Services Coordinator over here (acute psychiatric unit)."

CMS Form 729 - Medical Staff Coverage, completed by the facility on 6/12/12, indicated that the facility utilized one Family Practice physician part-time and one Physician's Assistant part-time.

B. Interviews

1. In an interview on 6/11/12 at 2:45p.m., RN1 stated that the Primary Care physician is available by phone "when we need him, but they (the doctors) rely on us (nurses) to call them if there's a problem." RN1 also confirmed that the primary care providers do not attend treatment team meetings and that MD1 did not come in to see Patient C1 prior to transfer to a community hospital for emergency medical care.

2. In an interview on 6/12/12 at 11:30a.m., RN2 confirmed the information that RN1 had reported the day before about physician coverage.

3. In an interview on 6/12/12 at 3:45p.m., the Medical Director admitted that the facility did not have enough primary care coverage by a physician. She stated that the physician's assistant had been reassigned last week to working in the skilled nursing home portion of the facility as was only available as a "backup to the psychiatric nurse practitioner." The Medical Director described the primary care physician's duties as "being available by phone twenty four hours a day, coming in on one weekend a month to cover admissions, but he has no set hours for direct care per se." The Medical director also stated "We're just now learning how to do things here."

I. Based on record review and interview, the Medical Director failed to ensure that Admission History and Physical Examinations were countersigned by a physician in a timely manner for 5 of 8 active sample patients who had examinations performed by an allied health professional (C2, C3, C4, S3 and S4). This failure of oversight places patients at risk of not having a medical diagnosis confirmed by a physician prior to the facility initiating treatment.

Findings include:

A. Record/Document Review

1. Patient C2: A History and Physical examination was completed by a physician's assistant on 5/25/12 and had not been signed by a physician as of the last day of the survey, 6/13/12.

2. Patient C3: A History and Physical examination was completed by a physician's assistant on 5/25/12 and had not been signed by a physician as of the last day of the survey, 6/13/12.

3. Patient C4: A History and Physical examination was completed by a physician's assistant on 5/27/12 and had not been signed by a physician as of the last day of the survey, 6/13/12.

4. Patient S3: A History and Physical examination was completed by a physician's assistant on 6/8/12 and had not been signed by a physician as of the last day of the survey, 6/13/12.

5. Patient S4: A History and Physical examination was completed by a physician's assistant on 6/10/12 and had not been signed by a physician as of the last day of the survey, 6/13/12.

6. The Hospital Medical Staff Rules and Regulations notes under Section 5.5: "Admission Documentation: An admission history and physical examination, including initial plan of treatment, mental status examination, diagnosis and estimated length of stay, shall be completed and dictated within twenty-four (24) hours after admission of the patient."

B. Interview

In an interview on 6/12/12 at 3:45p.m., the Medical Director agreed that the History and Physical examinations noted above did not meet the facility ' s requirement for completion by a physician.

II. Based on death record reviews and interviews, the Medical Director failed to develop a method of evaluating and documenting death reviews for 3 of 3 death records reviewed (X1, X2 and X3). Although the administrative staff asserted that reviews were done both by the Director of Quality Improvement and the Medical Staff at committee meetings, no documentation of any reviews was produced for any of the death records. This failure precludes the development of any action plans to address possible areas of deficiency related to deaths at the facility.

Findings include:

A. Record Review

1. The facility produced three patient death records to review. Patient X1 expired 4/21/11; Patient X2 expired 1/12/12 and Patient X3 expired 3/22/12. The Director of Nursing (in her capacity as Director of Quality Improvement) stated to the surveyors on 6/12/12 at 9:30am that there were morbidity/mortality reviews for each of those patients. She was unable to produce any documentation during the entire survey.

2. Medical Executive Committee meeting minutes were reviewed for the last year; there was no evidence that any of the three patients' records were discussed by the committee. Medical Staff meeting minutes were reviewed; there was one handwritten page of notes for a meeting in March 2012, the only meeting between 10/2011 and 6/2012; there was no evidence that any of the deaths were discussed in the one handwritten note page dated 3/2012.

B. Interviews

1. In an interview on 6/11/12 at 10:15a.m., the Chief Executive Officer reported that there were three death reviews completed by the Director of Nursing (in her capacity as Director of Quality Improvement), but that the DON wasn't back from vacation yet, and the CEO did not have access to the files.

2. In an interview on 6/12/12 at 9:30a.m., the Director of Nursing (in her capacity as Director of Quality Improvement) reported that she had the death reviews on her computer and would copy them for review. On 6/12/12 at 12p.m., the Director of Nursing (in her capacity as Director of Quality Improvement) admitted that she did not have any reviews for evaluation. The DON stated, "I looked at the nursing part of it but I wrote nothing down." When asked if there had been any committee meetings discussing these deaths, the DON stated "no."

3. In an interview on 6/12/12 at 3:45p.m., the Medical Director assured the surveyors that the medical staff had reviewed each of the deaths in the monthly medical staff committee meetings, but stated that there weren't any notes for any of those meetings. She later admitted that the death reviews never occurred.

Additionally, the Medical Director failed to:

III. Ensure that physicians provided a complete psychiatric evaluation within 60 hours of admission for 3 of 8 active sample patients (C2, C3 and C4). This failure can result in the treatment team not having enough input from the treating physician for the development of a comprehensive treatment plan. (Refer to B111)

IV. Ensure that physicians listed patient assets in the psychiatric assessment in descriptive, not interpretive, fashion for 3 of 8 active sample patients (C2, C3 and 4). This lack of information hinders the physician's ability to guide the team in developing a plan of care that builds on the patient's assets/strengths. (Refer to B117)

V. Ensure that clinical staff developed a comprehensive treatment plan that included identified acute medical problems for 1 of 8 active sample patients (C1). The patient needed transfer to a community emergency department for stabilization of ongoing medical illnesses. Failure to include acute medical problems as part of the Master Treatment Plan places patients at risk for exacerbation of medical problems. (Refer to B118-I)

VI. Ensure that Master Treatment Plans of 4 of 4 active sample patients who had been in the facility longer than one week (C1, C2, C3 and C4) were adequately developed and reviewed/updated by the interdisciplinary team. Failure to provide comprehensive treatment plans for patients, with reviews/updates on a regular basis, hampers the staff's ability to document patient progress for identified problems, potentially leaving acute problems unresolved at the time of discharge. (Refer to B118-II)

VII. Ensure that the Master Treatment Plan (MTP) included an inventory of the patient's strengths for 4 of 4 active sample patients (C1, C2, C3 and C5) who had been in the hospital long enough for staff to complete a Master Treatment Plan. This failure hampers staff's ability to determine how patient strengths can be utilized in treatment. (Refer to B119)

VIII. Ensure that the Master Treatment Plan (MTP) included substantiated diagnoses, both psychiatric and medical, based on input from the treatment team for 4 of 4 sample patients who had been in the hospital long enough for staff to complete a master treatment plan (C1, C2, C3, and C4). This failure impacts the development of comprehensive MTPs which direct and guide effective treatment planning/ patient care. (Refer to B120)

IX. Ensure that clinical staff provided Master Treatment Plans (MTPs) that identified short term (ST) and long term (LT) goals stated in observable, measurable, behavioral terms for 4 of 4 active sample patients who had been in the hospital long enough for staff to complete a Master Treatment Plan (C1, C2, C3, and C4). This failure impacts treatment for patients who do not have goals which are individualized, measurable or based on desired patient care outcomes. (Refer to B121)

X. Ensure that the Master Treatment Plans (MTPs) for 4 of 4 active sample patients who had been hospitalized long enough to have MTPs completed (C1, C2, C3 and C4) included physician, recreation therapy and occupation therapy interventions. Social Work interventions were missing on the MTP for 1 of the 4 patients (C1) and were generic tasks for the other 3 patients (C2, C3 and C4). Nursing interventions also were stated as generic tasks. The listed interventions also did not specify the focus of the individual and/or group modalities for the patients or list the frequency of the sessions. These deficiencies show a lack of integrated and comprehensive multidisciplinary treatment planning, and result in treatment plans that do not adequately specify individualized interventions for active treatment. (Refer to B122)

XI. Ensure proper documentation of patient records. Review of treatment plan sheets revealed that staff members, including the Medical Director, amended the Master Treatment Plans of four of four plans reviewed (C1, C2, C3 and C4) without properly dating the amendments. Failure to properly document patient records results in documents that do not accurately reflect the activities of staff related to patient care. (Refer to B125)

XII. Ensure that the medical staff provided a discharge summary that summarized all the treatment received in the hospital and the patient's response (or non-response) to treatment for 1 of 2 active sample patients who were transferred to the community hospital emergency department for acute medical care (C1). The patient experienced a medical crisis; the discharge summary did not provide any information about the situation or any care that had been attempted to address the issue prior to transfer. This failure compromises the effective transfer of the patient's care to the next care provider by failing to provide information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133-I)

XIII. Ensure that discharge summaries were signed by the attending physician within 15 days of discharge in 2 of 5 discharge records reviewed (D2 and D5). This deficiency results in discharge summaries that include final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan being sent out to outpatient providers prior to review by the attending physician.(Refer to B133-II)

XIV. Ensure that the date and time for follow-up appointments was included in the discharge summaries of 5 of 5 discharge records reviewed (D1, D2, D3, D4 and D5). The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)

XV. Employ a medical physician for an adequate number of hours to provide direct patient care, treatment team participation, and supervision of allied health professionals. The facility utilized a single primary care physician on a part time basis as a Consultant and for once-a-month weekend coverage. The physician was not available for the direct in house supervision of an active patient (C1) who had experienced an exacerbation of cardiac problems, necessitating emergency transfer to a community hospital emergency department for evaluation. The failure to provide sufficient medical supervision by a physician places patients at risk for increased complications of medical conditions. (Refer to B142)

Based on record review and staff interview, it was determined that the Director of Nursing had insufficient education and experience for her current administrative position as Nurse Executive in the facility. This deficient practice can result in lack of quality nursing care for the patients.
Findings include:

A. Document Review

Review of the Director of Nursing's curriculum vitae (CV) revealed that the Director of Nursing (hired after serving as a consultant following a state survey in September 2011) had a Master of Science in Nursing (MSN) degree (focus in Healthcare Administration), and a Master of Business Administration (MBA) degree from the University of Phoenix. The CV highlighted the DON's work experience in Long Term Care settings with patients diagnosed with Dementia and Alzheimer's Dementia (listed on the CV under "previous work experiences" before 2000). Additional listed work experience included: Director of Nursing, Nursing Supervisor, Nursing Coordinator, Staff Nurse and Case Management, and Consulting assignments.

B. Interview

1. During an interview on 6/12/12 at 3p.m., the Director of Nursing (DON) stated that she had MSN and MBA degrees, clarifying that her MSN degree was in "Healthcare Administration" and not Psychiatric Mental Health Nursing. She stated that she had additional work experience with psychiatric patients via " working with patients having Alzheimer and dementia." She also stated that she helped build two units in Columbus, OH (listed on the CV under "previous positions" before 2000). She acknowledged that the current psychiatric hospital unit included adults over the age of 18, as well as an older adult population. The DON agreed that she did not have work experience with psychiatric populations other than the older adults in long term care settings. The DON said she had obtained Continuing Education Credits (CEUs) related to caring for psychiatric patients, and that she retained copies of the CEU certificates required for licensure.

2. On 6/13/12, the RN surveyor requested to review the above CEU documentation to evaluate the DON's qualifications. The DON stated that she did not have the documentation on site and said, "It is in my home in Ohio."

Based on record review and interview, it was determined that the Director of Nursing (DON) failed to ensure the quality of nursing input in the development of the Master Treatment Plan (MTP), and failed to ensure that physician telephone transfer orders were correctly documented in the medical record for patient C1 who was transferred to another facility for emergency medical care. Specifically, the DON failed to:

I. Assure that the MTP's for 4 of 4 active sample patients (C1, C2, C3 and C4) specified nursing interventions that were individualized for the patients. Most of the listed nursing interventions on the treatment plans were generic nursing tasks which included no specified frequency or focus. The interventions were also identical or very similar for all patients with the same identified problems. Failure to document individualized nursing interventions on patients' treatment plans hampers the staff ' s ability to assure consistency of treatment, and can result in failure to deliver effective interventions.

II. Assure that a verbal physician order for transfer of a patient (Patient C1) to a community hospital for emergency medical care was correctly documented in the patient's medical record. Patient C1 was transferred to the community hospital for emergency medical care on 6/11/12. The Physician Orders for the patient contained no documented telephone order for the patient's transfer to the community hospital. Failure to document physician orders hampers staff communications and can result in adverse outcomes for patients.

Findings include:

I. Lack of Individualized Nursing Interventions on MTPs

A. Record Review

1. Patient C1 (admitted 6/2/12; MTP 6/2/12).

a. "Problem #1: Fall risk" - Generic Nursing Interventions: "Place on fall precautions, monitor and document in pt. chart. Obtain orthostatic blood pressure as ordered by MD and PRN. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall prevention x1, reinforce as needed."

b. "Problem #2: Depressed mood" - Generic Nursing Interventions: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping & participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in____. One-on-one to allow pt. to express feelings, use silence and active listening, document pt.'s response."

c. "Problem#3: Discharge planning" - Generic Nursing Interventions: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt., just prior to discharge, provide copy of discharge planning to pt."

d. The above nursing interventions listed for Fall Risk and Depressed Mood were the same or very similar for all patients with these same problems. The discharge planning interventions also were the same as those for the other patients. The added lines for individualization of the plans for the patient were left blank. In addition, the MTP did not specify the therapeutic group modalities and frequency for the listed interventions.

2. Patient C2 (admitted 5/25/12; MTP 5/26/12).

a. "Problem#1: Confusion" - Generic Nursing Interventions: "Assess level of confusion/disorientation each shift. Monitor the need for assistance each shift & encourage independence. Give clear, simple explanations and allow time for pt. to complete task, document pt. response. Assist pt. daily with personal hygien (sic) when pt. unable to complete, document pt. response."

b. "Problem #2: Anxiety" - Generic Nursing Interventions: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and state side effects, document in the chart and report to MD. Offer PRN medications ordered by the MD to help with anxiety. Assist pt. to identify early signs to anxiety to develop interventions to assist pt. during these times. Have pt. document in: ___. Encourage pt. to participate in daily activities and groups, provide positive feedback for accomplishments. Assist pt. to practice relaxation techniques when experiencing anxiety."

c. "Problem #3 Discharge planning" - Generic Nursing Interventions: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt. just prior to discharge, provide a copy of discharge planning to pt."

d. The nursing interventions above for Confusion and Anxiety were the same or very similar for all patients who had these identified problems. The discharge planning interventions also were the same as those for the other patients. There were no comments on the blank lines to individualize the plans for the patient. In addition, the MTP did not specify the therapeutic group modalities and frequency for the listed interventions.

3. Patient C3 (admitted 5/25/12; MTP 5/26/12).

a. "Problem #1: Depressed mood" - Generic Nursing Interventions: "Complete medication education and obtain consent on each psychotropic medication prior to initial dose. Document if unable to obtain. Monitor medication effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping and participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in her journaling."

b. "Problem #2: Fall risk" - Generic Nursing Interventions: "Place on fall precautions, monitor and document in the pt. chart. Obtain orthostatic blood pressure as ordered by MD and PRN. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related to ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall prevention x1, reinforce as needed."

c. "Problem #3 Discharge planning" - Generic Nursing Interventions: "Assist pt. to identify his/her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow up appointments with the pt. just prior to discharge, provide copy of discharge planning to pt."

d. The nursing interventions above for Depressed Mood and Fall Risk were the same or very similar for all patients who had these identified problems. The discharge planning interventions also were the same as those for other patients. There were no comments on the blank lines to individualize the treatment plan for the patient. In addition, the MTP did not specify the therapeutic group modalities and frequency for the listed interventions.

4. Patient C4 (admitted 5/27/12, MTP 5/27/12).

a. "Problem #1: Confusion" - Generic Nursing Interventions: "Assess level of confusion/ disorientation each shift. Monitor the need for assistance each shift & encourage independence. Give clear, simple explanations and allow time for pt. to complete task, document pt. response. Assist pt. with personal hygien [sic] when pt. unable to complete document pt. response."

b. "Problem #2: Depressed mood" - Generic Nursing Interventions: "Monitor medications effectiveness and side effects, document in the chart and report to MD. Provide clear limits regarding time spent in bed sleeping and participating in unit activities and groups. Explore with the pt. his/ her personal strengths, have pt. document in __. One-on one allow pt. to express feelings, use silence and active listening, document pt. response."

c. "Problem #3: Fall risk" - Generic Nursing Interventions: "Place on fall precautions, monitor and document in pt. chart. Assess pt. gait when ambulating; obtain consults for PT if indicated. Assess for medication related to ambulatory problems during waking hours, document and report to MD any changes. Instruct pt. not to get out of bed without assistance as needed. Educate pt. on fall preventionx1, reinforce as needed."

d. "Problem #4: Discharge Planning" -- Generic Nursing Interventions: "Assist pt. to identify his/ her goals and expectations for after discharge. Assist pt. to list all medications, identify times to be taken and amount of medications. Teach pt. about his/ her illness prior to discharge and identify signs and symptoms of relapse. Review all follow-up appointments with the pt. just prior to discharge, provide copy of discharge planning to pt."

e. The nursing interventions above for Confusion, Depressed Mood, and Fall Risk were identical or very similar for all patients who had these identified problems. The discharge planning interventions also were the same as those for other patients. There were no comments on the blank lines to individualize the treatment plan for this patient. In addition, the MTP did not specify the therapeutic group modalities and frequency for the listed interventions.

B. Interview

In an interview on 6/12/12 at 3p.m., after reviewing the treatment plans for patients C1 and C2, the Director of Nursing (DON) acknowledged that nursing interventions were documented using a check box form, and that the interventions were not individualized for the patients. She also acknowledged that the MTPs did not specify the specific therapeutic group modalities and the frequency for the listed nursing interventions.

II. Lack of Telephone Order documented in the Physicians Orders.

Patient C1 was admitted to the facility on 6/2/12. A review of documentation in the patient's medical record on 6/12/12 revealed that the patient had a medical emergency on 6/11/12 and was transferred to a community hospital. Nursing progress notes included documentation that a RN contacted the MD regarding the patient's change of condition, and that the nurse received a verbal telephone order for the transfer of the patient to the community hospital for emergency medical care. However, the verbal MD order was not documented as a Physician's order in the medical record.

When the Director of Nursing (DON) was informed that a MD order was not written in the medical record for patient C1's transferred to the community medical facility for emergency medical care, the DON stated, "Yes an order would be expected to be written." The DON was clarifying that when the RN contacted the physician by phone and received the telephone order, the order was expected to be written as a Physician's Order in the medical record.

Based on document review and interviews, the facility failed to provide or have available psychological services. This deficiency compromises the facility's ability to address all of the patient's problems and needs in a timely manner.

Findings include:

A. Document Review

Review of the facility's medical staff roster failed to identify any psychology specialists having privileges at the facility.

B. Interviews

1. In an interview on 6/12/12 at 3:45p.m., the Medical Director confirmed that the facility did not have any psychology specialists on the medical staff or available by contract for consultation.

2. In an interview on 6/13/12 at 11:15a.m., the Chief Executive Officer confirmed that there were no psychology specialists on staff or available by contract for services at the facility.

I. Based on record review and interview, the facility failed to provide social work assessment updates that included conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for 2 of 2 active sample patients readmitted to the facility (C3 and S1). This failure can result in a lack of professional social work services for patients and/or lack of input to the treatment team.

Findings include:

A. Record Review

1. Patient C3 was readmitted to the facility on 5/25/12. A Social History from a previous admission on 12/23/10 was in the medical record. A Social History Update, dated 5/26/12, failed to include any conclusions or recommendations for social work intervention during the current admission.

2. Patient S1 was readmitted to the facility on 6/8/12. A Social History Update (undated and unsigned) was present in the record. The update failed to include any conclusions or recommendations for social work intervention during the admission. No original Social History was present in the record from the previous admission.

B. Interview

In an interview on 6/13/12 at 11a.m., after reviewing the records for patients C3 and S1, the Director of Social Services stated, "We don't really have a policy about how and when to do updates." She acknowledged that the two updates did not include recommendations or conclusions for social work interventions.

Based on document review and interview, the facility failed to provide a Director of Social Work who possessed a Master's degree in social work. There was a part time Master's prepared social worker on staff, yet there was no evidence of any peer review process or supervision. This failure can lead to lack of needed social services for patients.

A. Document Review

1. Review of the resume for the Director of Social Services revealed the following under education: "Bachelor of Arts, Social Work; Idaho State University."

2. The resume for the other social work staff member, who works part time (mostly on weekends), included documentation of completion of a Masters of Social Work at the University of Utah.

3. The surveyors were unable to obtain any records that showed ongoing peer review, supervision or monitoring of social work activities in the facility.

B. Interview

In an interview on 4/13/12 at 10:30a.m., the Director of Social Work confirmed the above findings and acknowledged that quality review of social work performance was not documented anywhere within the facility.