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Based on record review and interview, it was determined that in 8 of 8 active patient records reviewed (A, B, C, D, E, F, G and H) the hospital failed to perform and record detailed neurological findings. The "History and Physical." included a preprinted table with four columns listing "Norm, Abn [abnormal], Item and Note." Under "Neurologic," findings for "finger-to- nose" were not documented. Findings for Cranial Nerves VIII and XII and presence/absence of a "Babinski" also were not documented. These failures could result in the overlooking of treatable neurological conditions, inability to determine changes from baseline status during patients' hospital stay, and difficulty ascertaining progression/worsening of the patient's condition on subsequent re-examination.

Findings are:

A. Record review

1. Patient A was admitted on 12/18/09 with the chief complaint of "isolative, delusional and psychotic." The AXIS I diagnosis was "Agoraphobia with panic disorder." In the "History and Physical" examination done on 12/18/09, the Neurologic Examination for finger-to-nose and Cranial Nerve VIII and XII were not documented.

2. Patient B was admitted on 02/02/10 with the chief complaint of "depression - suicide ideation." In the "History and Physical" examination done on 02/03/10, the Neurologic Examination findings for "finger-to-nose" and "Cranial Nerve XII" were not documented. The signature of the Attending Physician did not document the time that the physical examination was completed.

3. Patient C was admitted on 02/08/10 with the chief complaint of "get off drugs." The patient's AXIS I diagnosis was "schizoaffective disorder, polysubstance depression." In the "History and Physical" examination done on 02/08/10, the Neurologic Examination for "finger-to-nose," "Absence of EPS" and Cranial Nerve XII was not documented.

4. Patient D was admitted on 02/12/10 with chief complaint of "Alcoholism." The AXIS I diagnosis listed "Bipolar, Alcohol dependence." In the "History and Physical" examination done on 02/12/10, the Neurologic Examination for "finger-to-nose" and "Sensory testing" was not documented.

5. Patient E was admitted on 12/30/09 with the chief complaint of "depression/Bipolar." The AXIS I diagnosis listed "Alcohol dependence, Bipolar Disorder/mixed." In the "History and Physical" examination done on 12/31/09, the Neurologic Examination findings for Cranial Nerves II, III, IV, V, VI and VII were not completed.

6. Patient F was admitted on 01/25/10 with the chief complaint of "Paranoia." The AXIS I diagnosis listed "Bipolar depressed, Opiate abuse." In the "History and Physical" examination done on 01/26/10, the Neurologic Examination for "finger-to-nose" testing was not documented.

7. Patient G was admitted on 02/08/10 with the chief complaint of "depression, alcoholism, Marijuana addiction." The AXIS I diagnosis listed "r/o Bipolar disorder." In the "History and Physical" examination done on 02/08/10, the Neurologic Examination for "finger-to-nose" testing was not documented.

8. Patient H was admitted on 02/09/10 with the chief complaint of "Marijuana addiction, I am here for rehab." The AXIS I diagnosis listed "Schizoaffective disorder, drug dependence." In the "History and Physical" examination done on 02/10/10, the Neurologic Examination for "finger-to-nose" testing was not documented.

B. Interview

1. In an interview on 02/17/09 at 10:30 AM, Physician I acknowledged that the History and Physical Examinations did not include descriptive screening neurological examinations.

2. In an interview on 02/16/09 at 1:00 PM, the DON was shown the sample patient's Neurologic Examinations and acknowledged that they were incomplete.

Based on record review and interview, the facility failed to ensure that 8 of 8 sample patients (A, B, C, D, E, F, G and H ) received a psychiatric evaluation that included estimates of intellectual and memory functioning and orientation. The "psychiatric assessment" contained a section titled "Mental Status Exam: (for estimated intellectual functioning, memory and orientation)." There were boxes to document the scores and instructions to "address each area with a numerical number and total score" and to include "triggers." These areas were either blank or contained a line drawn through them. Failure to document findings from intellectual and memory functioning and orientation hampers the identification of pathology that may be pertinent to the current mental illness. It also results in inability to do future comparative re-examinations to assess patients' responses to treatment interventions.

Findings are:

A. Record Review

The psychiatric assessments (dates in parentheses) of sample patients A (12/19/09), B (2/02/10), C (2/08/10), D (12/19/09), E (undated), F (1/26/10), G (2/09/10) and H (2/10/10) included no estimates of intellect, memory functioning and orientation. The assessments were either blank or contained a line drawn through with no supportive information documented.

B. Interview

1. In an interview on 02/16/10 at 1:30 PM, the Medical Director acknowledged that the psychiatric evaluations did not document supportive information that justified conclusions about an estimate of intellectual functioning, memory functioning, or orientation.

2. In an interview on 02/16/10 from 2:15 PM - 3:00 PM, Physician II was questioned as to when estimated intellectual functioning, memory and orientation were completed. Physician II replied "If there is no cognitive impairment, I do not do one; if there is a cognitive impairment, I certainly would do one."

Based on record review and interview, it was determined that the facility failed to identify specific staff persons responsible for interventions listed on the treatment plans of 8 of 8 sample patients (A, B, C, D, E, F, G and H). In all 8 treatment plans, interventions were assigned to disciplines rather than to individual team members. This type of staff assignment diffuses staff responsibility and hampers the facility's ability to hold staff accountable for essential treatment tasks.

A. Record Review

1. Patient A had had no comprehensive Master Treatment Plan and no staff members were identified as being responsible for any interventions.

2. Patient B had the following different generic treatment plans: a) Altered Thought Treatment Plan (dated 2/2/10), b) Depression Treatment Plan (dated 2/2/10), and c) Anxiety Treatment Plan (dated 2/2/10). Interventions listed were "in therapy group held 1xweekly for 1 hour," The staff member to provide the therapy was written as "therapist." No specific name was given for that particular intervention.

3. Patient C had a "Depression Treatment Plan" developed on 2/8/10 which listed group therapy as a modality. The Plan only said "therapist" as the responsible staff. No specific staff was named as the responsible person for the intervention.

4. Patient D had a "Depression Treatment Plan" developed on 2/12/10. The Plan listed group therapy intervention. It only listed "therapist" as the responsible person for the intervention.

5. Patient E had a "Depression Treatment Plan" developed on 12/30/09 which had "group therapy" 1xweek as an intervention. The word "therapist" was listed as being responsible for the intervention.

6. Patient F had an "Altered Thought Treatment Plan " developed on 1/25/10. The "psychiatrist" and "nurse" were listed as responsible to see the patient for medication management and carry out group therapy sessions twice/week, respectively.

7. Patient G had a "Depression/Anxiety Treatment Plan" developed on 2/8/10. The Plan listed "Psychiatrist," "nurse," and "therapist" as the responsible staff members to carry out a "group" therapy session 1xweekly. This patient also had an "Alcohol Dependence Treatment Plan" developed on 2/8/10 which listed "therapist," "psychiatrist," and "case manager" as responsible staff members to carry out the therapeutic interventions.

B. Interview:

In an interview of 2/16/10 at 11:00 AM., the Medical Director agreed with the surveyor's assessment that responsibility to carry out specific treatment intervention was not given to specific staff. Instead, it was assigned to disciplines, thus having a potential for confusion, diffusion of responsibility and lack of accountability.

Based on observation, and interview and record review, the Medical Director failed to:

I. Assure that the hospital performed and recorded detailed neurological findings for 8 of 8 active sample patients (A, B, C, D, E, F, G and H). The "History and Physical" exams included a preprinted table with four columns listing "Norm, Abn [abnormal], Item and Note." Under "Neurologic," findings for "finger - to - nose" were not documented. Findings for Cranial Nerves VIII and XII and presence/absence of a "Babinski" also were not documented. These failures could result in the overlooking of treatable neurological conditions, inability to determine changes from baseline status during patients' hospital stay, and difficulty ascertaining progression/worsening of the patient's condition on subsequent re-examination. (Refer to B109).

II. Ensure that 8 of 8 active sample patients (A, B, C, D, E, F, G and H) received a psychiatric evaluation that included estimates of intellectual and memory functioning and orientation. The "psychiatric assessment" contained a section titled "Mental Status Exam: (for estimated intellectual functioning, memory and orientation)." There were instructions to "address each area with a numerical number and total score" and to include triggers with boxes to document the scores. These areas were either blank or contained a line drawn through them. Failure to document specific intellect, memory and orientation testing compromises the identification of pathology which may be pertinent to the current mental illness and hampers future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116).

III. Ensure that the Master Treatment Plans for 8 of 8 sample patients (A, B, C, D, E, F, G, and H) identified specific staff members responsible for the interventions. In all 8 treatment plans, interventions were assigned to disciplines rather than to individual team members. This type of staff assignment diffuses staff responsibility and hampers the facility's ability to hold staff accountable for essential treatment tasks. (Refer to B123).

Based on policy review, record review and interview, the facility failed to: a) provide adequate numbers of qualified activity therapists and support personnel to provide individual assessments, re-evaluation and ongoing treatment for 8 of 8 sample patients (A, B, C, D, E, F, G and H), and b) develop treatment plans that included specific responsibilities for therapeutic activity staff in the care of 8 of 8 sample patients (A, B, C, D, E, F, G and H). These deficiencies resulted in the absence of therapeutic activities being provided in an individualized manner to meet the patients ' needs. Failure to ensure adequate numbers of qualified rehabilitation program staff results in patients not receiving the full range of treatment resources that can help them obtain skills for returning to the community.

Findings are:

A. Policy Review

The facility policy titled " Planning for Delivery of Activity Therapy, Subject - Clinical Activity Therapy Number CL -5:001, " page(s) 3 of 6 states " ...services are provided as specified in the policies of the clinical manual in accordance with program objectives. " The policy did not include the role of the activity therapist in initiating and completing AT assessments.

B. Record Review

Review of the medical records for active sample patients A, B, C, D, E, F, G and H revealed no activity therapy assessments.

C. Interview

1. In an interview on 02/16/10 at 1:30 PM, the Activity Therapist (AT) stated " No formal activity assessment is completed. I do an informal one within one week of admission. " When questioned as to his participation in treatment planning meetings, the AT stated that he does not attend the meetings.

2. In an interview on 02/16/10 at 4:30 PM, the CEO acknowledged that no formal activity assessments were being done.