HospitalInspections.org

Based on policies and procedure reviews, medical record reviews, patient and staff interviews and observations, the facility failed to:

I. Ensure that the social work assessments for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) included recommendations regarding the role of the social worker in treatment and discharge planning, and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community. (Refer to B108)

II. Ensure that the psychiatric evaluations of 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) contained sufficient documentation of specific signs, symptoms, precipitating factors, and course of illness to justify the diagnosis(es) that formed the basis for the proposed treatment. Failure to provide the necessary information to justify the diagnosis impedes the treatment team's ability to formulate a meaningful plan of care designed to meet the patient's individual needs. (Refer to B110)

III. Ensure that the psychiatric evaluations of 5 of 8 sample patients (A1, A5, A8, B1 and B7) included an inventory of patient's assets in a descriptive, not interpretive fashion. Failure to describe personal strengths/assets compromises the treatment team's ability to develop a meaningful treatment plan and limits the team's ability to engage the patient in therapy. (Refer to B117)

IV. Ensure that the Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) were comprehensive (contained all appropriate elements to guide staff in providing optimal treatment). Specifically, the facility failed to provide MTPs that included: 1) an inventory of patient strengths and disabilities (Refer to B119); 2) substantiated diagnosis (Refer to B120); 3) individualized short-term goals, described in observable and/or measurable terms, and written as patient goals rather than staff goals (Refer to B 121); and 4) individualized treatment modalities (Refer to B122).
Failure to develop Master Treatment Plans that contain all appropriate elements to guide staff in providing treatment (i.e. substantiated diagnoses, individualized and measurable short-term goals, and individualized treatment modalities) compromises the team's ability to effectively address the patients' problems and to meet the patients' needs for successful and timely return to the community.

V. Ensure that the patient's responses to the interventions listed on the "Interdisciplinary Treatment Plans" were documented. Specifically, there was no documentation in the medical record or on "Group Evaluation Forms" regarding the patient's attendance at treatment, topics discussed, and/or the patient's responses to the intervention (level of participation and understanding) by Registered Nurses for 3 of 8 active sample patients (A4, B1, and B6); by Therapeutic Activities staff for 4 of 4 active sample patients (A1, A4, A5, and A8) at the INN, and by Counseling staff for 4 of 4 active sample patients (B1, B6, B7, and B8) at the UNIT. This failure hampers the treatment team's ability to determine patients' progress or lack of progress related to specific treatment interventions and to revise the treatment plan as needed. (Refer to B124)

VI. Ensure proper documentation of seclusion and restraint for 1 of 1 non-sample Patients (B10) whose record was reviewed for seclusion and restraint procedures. Six restraint episodes occurred with patient B10 between 4/03/10 and 4/10/10. In four instances, the physician's assessment within one hour of the restraint was documented late or not documented; and in 4 additional instances the physician's documentation authorizing release from restraint was not documented, as the form required. These failures expose patients to potential harm from unnecessary seclusion or restraint, and violate the patients' right to be free from restraint except to prevent immediate harm to self or others. (Refer to B125)
VII. Ensure that attending psychiatrists completed discharge summaries that included detailed information regarding the rationale for and the course of treatment during hospitalization, and described discharge plans, including follow-up community-based services and supports appropriate to the patient's needs. Failure to provide discharge summaries that identify effective and/or ineffective treatment strategies for individual patients compromises the effective transfer of the patient's care to the next care provider. (Refer to B133 and B134)

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

I. Ensure that the Clinical Director monitors and evaluates the quality and effectiveness of the treatment program to assure that patients receive the intensity and quality of care appropriate to their needs. This results in a lack of guidance for staff in the provision of patient treatment and the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B144)

II. Ensure adequate clinical leadership in nursing to monitor nursing documentation, active treatment provided, and staffing effectiveness. This results in lack of guidance to nursing staff in providing care, potentially resulting in inconsistent and/or ineffective treatment. (Refer to B148)

III. Ensure that adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Mental Health Associates (MHAs) were deployed to provide nursing care, supervise, and monitor patients. Registered Nurses workload on the day and evening shifts required them to spend most of their time in the Nursing Station completing admissions, discharges, and other clinical paperwork. Additionally, on the night shift at the INN, where no RN was present, certified patients housed on the first floor were left unsupervised when MHAs were completing checks on the second and third floors. This staffing pattern results in the lack of involvement by RNs in active treatments measures outlined on the MTPs, lack of supervision of patients by nursing staff, and lack of direction and supervision of MHAs assigned to monitor patients. (Refer to B150)

IV. Employ sufficient numbers of qualified Therapeutic Activities staff to complete assessments and ensure appropriate input into the formulation of the "Interdisciplinary Treatment Plan." Specifically, there were no Activities Therapists available to complete assessments as stipulated in the facility's "Plan of Professional Services." There was only the Director of Therapeutic Activities and two therapy aides available to conduct therapeutic activities for patients on the UNIT with 20 beds and at the INN with 39 beds. In addition, the facility failed to ensure that therapeutic activities were available for patients after 3:00 p.m. during the week and on the weekends at the INN. This failed practice results in a limited number of planned therapeutic activities available to assist patients with skills necessary for relapse prevention and successful discharge. (Refer to B158)

Based on record review and interview, the facility failed to ensure that the social work assessments for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) included recommendations regarding the role of the social worker in treatment and discharge planning and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community.

Findings are:

A. Record Review

The psychosocial assessments of the following patients were reviewed (dates of evaluations are in parentheses): A1 (2/25/10-original; 4/07/10-update); A4 (4/09/10); A5 (4/07/10); A8 (4/05/10); B1 (3/29/10); B6 (4/09/10); B7 (4/12/10); and B8 (4/12/10). This review revealed:

1. Patient A1: In the original psychosocial assessment's section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote "coordinate discharge planning - encourage sobriety"; in the psychosocial update dated 4/07/10, no additional information on discharge alternatives or areas in need of exploration for the purposes of discharge planning was provided.

2. Patient A4: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning - encourage sobriety."

3. Patient A5: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning with outpatient providers."

4. Patient A8: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning with outpatient providers."

5. Patient B1: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge plans."

6. Patient B6: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning with outpatient providers."

7. Patient B7: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning - encourage coordination with aftercare providers."

8. Patient B8: In the section "Discharge Plans (include alternatives and areas requiring further exploration)," the social worker wrote, "coordinate discharge planning - encourage continued sobriety."

B. Staff Interview

An interview was conducted with the Director of Social Work on 4/12/10 at 4:10 p.m. In reviewing copies of the Psychosocial Assessments of the sample patients, the Social Work Director stated, "The psychosocials aren't great. I would like to change them but we are really understaffed and we don't have the time." She also said she didn't think her staff "understands the process of discharge planning" and that "they are way too busy just trying to keep up with the patient admissions and discharges. "

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) contained sufficient documentation of specific signs, symptoms, precipitating factors, course of illness and response to previous treatment(s) to justify the diagnosis/es. Failure to provide sufficient information to justify the diagnosis impedes the treatment team's ability to formulate a meaningful plan of care to meet the patient's individual needs.

Findings are:

A. Record Review

The psychiatric assessments (each included in a document entitled "History, Physical, and Psychiatric Evaluation") of the following patients were reviewed (dates of evaluations are in parentheses): A1 (4/05/10); A4 (4/09/10); A5 ( 4/06/10); A8 (4/04/10); B1 (3/26/10); B6 (4/08/10); B7 (4/09/10); and B8 (3/31/10-original; 4/09/10-readmission after brief triage to a general hospital for the evaluation of chest pain). The review revealed:

1. Patient A1: In the section labeled "presenting problem/present illness," information on the patient's diagnoses was "the patient has a history of PTSD and mood disorder." There was no documentation of the specifics of the past psychiatric history.

2. Patient A4: In the section labeled "presenting problem/present illness," information on the patient's diagnoses was "the patient says he has had depression 'all his life.' Recently he has been drinking in order to make the depression go away....The patient was treated in the past by a psychiatrist at HES for depression and he has been on Celexa, Prozac, Zoloft, and buspirone...." There was no section on past psychiatric history.

3. Patient A5: In the section labeled "presenting problem/present illness," information on the patient's diagnoses was "The patient describes a long history of problems with anxiety and depression as well as with alcoholism....The patient has continued to struggle with anxiety and depression....The patient states that he sees a prescriber and a therapist...." There was no section on past psychiatric history.

4. Patient A8: In the section labeled "past medical, trauma, abuse, and social/family history," was the statement "past psychiatric developmental [sic] history is remarkable for multiple inpatient admissions." No further description regarding the reason for the previous admissions or the treatment received was provided. There was no section on past psychiatric history.

5. Patient B1: In the section labeled "presenting problem/present illness," the information on the patient's diagnoses was "The patient has a long history of mental illness. She is followed by [physician name] and available information reveals that the patient stopped the Clozaril over a week ago and has been experimenting [sic] auditory hallucinations...." In the section labeled "past medical, trauma, abuse, and social/family history" was the statement "past psychiatric developmental [sic] history is remarkable for a long history of mental illness. She was at Baldpate around 20 years ago; most recently she has been at Bay Ridge...." Aside from mentioning these two hospital stays, no further detail on the reason for the previous admissions or the treatment received was provided. There also were no details on outpatient treatment, the patient's response to previous medications or the current medication despite the twenty-year history of psychiatric illness.

6. Patient B6: In the section labeled "presenting problem/present illness," information on the patient's diagnoses was "The patient started drinking alcohol when he started being a fisherman ....The patient was recently at [name of afacility] for Polysubstance dependence and bipolar disorder..." The patient presented as a committed patient (admitted under Massachusetts Section 12) "for suicidal ideation and thoughts of hanging himself or cutting himself." There were references to "multiple admissions" and "serious attempts to end his life." However, past psychiatric history supporting the diagnosis of Bipolar Disorder and describing previous specific treatment interventions and the patient's response were absent. Current clinical information describing the depth or the patient's current depression was absent.

7. Patient B7: In the section labeled "presenting problem/present illness," information on the patient's diagnoses was " The patient has a history of ADHD and says he has been very depressed for the past 24 hours...." The psychosocial assessment referred to the patient having Asperger's Syndrome, and the psychiatric assessment stated the patient was in special education classes. However, the evaluating psychiatrist made no reference to Asperger's Syndrome or autism spectrum disorders in the psychiatric evaluation dated 4/09/10. There was no section on past psychiatric history.

8. Patient B8: The original psychiatric assessment was dated 3/31/10. Although multiple recent and past hospitalizations were mentioned in the report, there was no description of the treatment provided in previous hospitalizations or the patient's response to the treatment. No explanation was provided regarding possible reasons for the current tactile hallucinations or double vision Organic conditions were not considered in the provisional diagnoses. The psychiatric assessment did not include a specific section on past psychiatric history. The 4/09/10 re-admission psychiatric assessment focused on the medical admission. It only provided details on the course of the medical work-up and results, ruling out a cardiac event.

B. Staff Interview

In an interview on 4/13/10 at 12:40 p.m., the Medical Director stated he did not conduct any systematic chart reviews to assess the quality of the assessments.

Based on record review and interview, the facility failed to provide psychiatric assessments that included an inventory of patient strengths/assets described in descriptive, not interpretive terms for 5 of 8 sample patients (A1, A5, A8, B1 and B7). Failure to describe personal strengths and/or attributes that patients bring to treatment compromises the treatment team's ability to develop meaningful treatment plans and limits the team's ability to engage patients in therapy.

Findings are:

A. Record Review

1. Patient A1 (psychiatric assessment 4/05/10): In the section entitled "Patient's Assets," the documentation only stated, "She does have an outside psychiatrist."

2. Patient A5 (psychiatric assessment 4/06/10): In the section entitled "Patient's Assets," the documentation only stated, "The patient responds well to supportive contact."

3. Patient A8 (psychiatric assessment 4/04/10): In the section entitled "Patient's Assets," the documentation only stated, "The patient is agreeable for treatment and future oriented."

4. Patient B1 (psychiatric assessment 3/26/10): In the section entitled "Patient's Assets," the documentation only stated, "The patient has a good and supportive family. She is well established at Network [sic] of outpatient services. She is on SSDI."

5. Patient B7 (psychiatric assessment 4/09/10): In the section entitled "Patient's Assets," the documentation only stated. "Parents, psychiatrist and psychologist."

B. Staff Interview

1. In an interview on 4/13/10 at 12:40 p.m., the Medical Director stated, "I agree" that having "disability insurance," or "a therapist," or "supportive parents" were "not examples of personal assets or strengths."

2. In an interview with RN1 on 4/14/10 at 11:00 a.m., the psychiatric assessments for sample patients B1 and B7 were reviewed. When looking at the sections on strengths/assets, RN1 stated "these are not personal assets...they are supports that the patient has."

Based on observations, record review and staff interviews, the facility failed to develop comprehensive Master Treatment Plans (MTPs) for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8). The MTPs failed to:

I. Include individualized short-term goals for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) that were stated in observable or measurable terms. The goals were vague and non-specific (unmeasurable) and/or were the same across patients with different diagnoses and presenting problems. The goals for 2 of 8 active sample patients (A5 and A8) were written as staff goals or interventions rather than patient goals. The absence of individualized short-term goals that reflect expected behavior change and functional improvement hampers the team's ability to determine whether the plan of care is effective. (Refer to B121)

II. Address the identified problems and needs of 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) with specific interventions. Instead of listing individualized treatment interventions, the MTPs only included generic and routine nursing functions (Refer to B122, Part I).

III. Specify how interventions would be delivered (group or individual modalities) and the frequency of treatment interventions for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) (Refer to B122, Part II); and include on the MTPs the groups that were listed on the group schedule and that were attended by 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, & B8). (Refer to B122, Part III)

The deficiencies in II and III result in failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention prescribed by the treatment team, potentially resulting in inconsistent and/or ineffective treatment.

IV. Ensure that the patient's responses to interventions listed on the "Interdisciplinary Treatment Plans" were documented. Specifically, there was no documentation in the medical records and "Group Evaluation Forms" regarding the patient's attendance, topics discussed, and/or patients' responses to the intervention (level of participation and understanding) by Registered Nurses for 3 of 8 active sample patients (A4, B1, and B6); by Therapeutic Activities staff for 4 of 4 active sample patients (A1, A4, A5, and A8) at the INN (a three story structure with a 39 bed capacity), and by Counseling staff for 4 of 4 active sample patients (B1, B6, B7, and B8) at the UNIT (a one story structure with a 20 bed capacity). This failure potentially hampers the treatment team's ability to determine patients' responses to treatment interventions and revise the treatment plan as needed (Refer to B124).

Based on record review and interview, the facility failed to ensure that treatment plans were based on an inventory of the patients' strengths for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, & B8). The plans for these patients listed general traits and/or supports as strengths that were not specific to the patient. In addition, treatment plan psychiatric problem statements (disabilities) were not always consistent with presenting problems noted in the psychiatric evaluations for 5 of 8 active sample patients (A1, A4, B1, B6, & B7). These failures diminish the effectiveness of treatment interventions by not engaging the patients through use of their known strengths.

Findings are:

A. Record Review

1. Patient A1 was admitted on 4/05/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/06/10, included only the following statement regarding assets: "Patient has supportive parents, are guardians [sic]" There was no inventory of strengths that could be used to help the patient address her presenting problems during hospitalization.

The ITP listed the psychiatric problem as "Depressed Mood" as evidenced by "...poor memory,...." This problem statement was not consistent with the psychiatric evaluation dated 4/05/10, which noted, "Memory appears intact for recent and remote events."

2. Patient A4 was admitted on 4/06/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/09/10, included the following statements as assets: "Patient was fired 2 months ago from job; pt [patient] has positive support [sic]; longest abstinent 3 months." These were not personal assets. There was no inventory of strengths that could help the patient address his presenting problems during hospitalization.

The ITP listed the psychiatric problem as "Depressed Mood" as evidenced by " increased energy, job loss, stress, poor sleep, poor judgment, poor insight." This problem statement did not address the patient's suicidal issues as documented in the psychiatric evaluation dated 4/09/10, which noted that the patient "has been drinking in order to make the depression go away...and deliberately took 15 blood pressure pills in order not to wake up..."

3. Patient A5 was admitted on 4/06/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/06/10, included only the following statement regarding assets: "Patient has 11th grade [sic], lives in supervised apartment, pt [patient] has job at ...." There was no inventory of strengths that could help the patient address his presenting problems during hospitalization.

4. Patient A8 was admitted on 4/04/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/05/10, included only the following statements regarding assets: "8th grade, unemployed." The plan did not state how having an "8th grade" education could be used to help the patient address the presenting problems, and being "unemployed" is not a personal asset. There was no other listing of patient strengths that could help the patient address the presenting problems during hospitalization.

5. Patient B1 was admitted on 3/26/10. The patient's updated "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 3/29/10, included the following statements regarding assets: "Patient has support of therapist/psychiatrist, denies substance abuse." These were not personal assets. There was no other listing of patient strengths that could be used to help the patient address her problems during hospitalization.

The ITP listed the psychiatric problem as "Potential for self-harm, mood instability." The problem statement did not address noncompliance with medication, hallucinations [loud voices], and not eating which were documented in the psychiatric evaluation dated 3/26/10, which noted, "The patient stopped taking Clozaril over a week ago and has been experiencing auditory hallucinations [loud voices]...she has not been eating for three days."

6. Patient B6 was admitted on 4/08/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/09/10, included only the following statement regarding assets: "8th grade education." The plan did not specify how this could be used to help the patient address his presenting problems. There was no other listing of strengths that could help the patient address his presenting problems during hospitalization.

The ITP listed the psychiatric problem as "Potential for self harm r/t [related to] depressed Mood" as evidenced by "...SI [suicidal ideation] with thoughts of cutting with a knife,...." This problem statement was not consistent with presenting problems in the psychiatric evaluation dated 4/08/10, which noted that the patient was not suicidal stating, "The patient's mood and affect are full-range and congruent. He is somewhat hopeless and depressed but not suicidal."

7. Patient B7 was admitted on 4/09/10. The patient's "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/09/10, included only the following statement regarding assets: "Trade School." The plan did not specify how this strength could be used to help the patient address his presenting problems during hospitalization. There was no other listing of patient strengths that could be used to help the patient address his presenting problems during hospitalization.

The ITP listed the psychiatric problem as "Potential for self harm r/t [related to] depressed mood" as evidenced by "...persecutory delusions,..." This problem statement was not consistent with the psychiatric evaluation dated 4/09/10, which noted, "There was no evidence of delusions."

8. Patient B8 was admitted on 3/31/10. The patient's updated "Interdisciplinary Treatment Plan (ITP)," signed by the Team Leader and Patient on 4/05/10, included the following statement regarding assets: "Pt [Patient] has support from shelter staff, homeless [sic], Pt [patient] is unemployed." These were not personal assets. The plan listed no strengths/assets that could be used to help patient address her presenting problems.


B. Staff Interviews

1. In an interview on 4/14/10 at 10:30 a.m., the treatment plans for sample patients A1, A4, A5 and A8 were reviewed. The Director of Substance Abuse for the INN confirmed that the treatment plans did not contain an inventory of assets for patients that could be used in treatment during their hospital stay. When comparing the problem statements on the treatment plans with the findings in the psychiatric evaluations, she agreed that the problem statements were vague and did not always describe presenting symptoms as noted in the psychiatric evaluation.

2. In an interview on 4/14/10 at 11:00 a.m., the "Assets (Inventory of Strengths from the Areas of Knowledge, Interests, Skills, Aptitudes, Experiences, Education, Employment Status)" sections of the "Interdisciplinary Treatment Plans" for Patients B1, B6, B7, and B8 were reviewed with RN1. When asked if any of the treatment plans appropriately documented the patient's assets as defined by the probe on the form, RN1 responded, "Not for B1, marginally for B6 and B7 and not at all for B8 --- some of what is listed is actually a risk for her."

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans included substantiated diagnoses that could serve as a basis for treatment 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and and B8). Instead, the provisional diagnoses on the psychiatric evaluation performed at the time of admission, were carried over to the Master Treatment Plans, without confirming or amending the provisional diagnoses by incorporating information from assessments performed by other disciplines, from laboratory studies, and/or from additional information obtained from collateral sources, or from patient and family interactions between the admission and the planning meeting.

Findings are:

A. Record review

The Interdisciplinary Treatment Plans (MTPs) or the following patients were reviewed (dates of MTPs in parentheses): A1 (4/06/10); A4 (4/09/10); A5 (4/07/10); A8 (4/05/10); B1 (3/29/10); B6 (4/09/10); B7 (4/09/10); and B8 (4/12/10). The review revealed that on all records, the psychiatric evaluation provisional diagnoses were copied onto Page One of the treatment plan. There was no documentation that the attending psychiatrist and other members of the treatment team had reviewed and confirmed (or amended) the preliminary diagnoses, based on data from the additional assessments.

B. Staff interview

In an interview on 4/13/10 at 12:40 p.m., the Medical Director stated that someone (he could not state who) simply copied the diagnoses verbatim from the provisional diagnosis/(es) listed on the psychiatric evaluations onto the treatment plan documents prior to the treatment planning meetings.

Based on record review and interview, the facility failed to ensure that the short-term goals on the Master Treatment Plans of 8 of the 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) were individualized and measurable. The goals were vague and non-specific (unmeasurable) and/or were the same across patients with different diagnoses and presenting problems. The goals for two of the eight sample patients (A5 and A8) were written as staff goals or interventions rather than patient goals. The absence of individualized short-term goals that can be used to document behavior change and functional improvement hampers the team's ability to determine whether the plan of care is effective.

Findings are:

A. Record Review

1. Patient A1's MTP, dated 4/06/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Patient will seek help." Social work: "Pt will improve depressed mood...will develop 1-3 community resources." Nursing: "Pt will report mood improvement." Activities Therapy: "Pt will choose and complete one project..." Counseling: "Pt will ID [identify] 3 coping skills per group to manage mood." These goals are nonspecific, are not measurable, and do not represent patient behavioral change.

2. Patient A4's MTP, dated 4/09/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Patient will be talking & taking help for depression." Social work: "Pt will improve depressed mood; pt will develop 1-3 community resources." Nursing: "Pt will report all mood changes to staff & not isolate." Activities Therapy: "Pt will choose and complete one preferred project per group with 100% frequency." Counseling: "Pt will ID 1-3 life stressors per group w/100% consistency." These goals are nonspecific, are not measurable, are tasks to complete, and do not represent patient behavioral change.

3. Patient A5's MTP, dated 4/07/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Patient will be seeking help & talking daily." Social Work: "Patient to improve mood." Nursing: "Make environment safe." Activities Therapy: "Pt. will ID 2 personal accomplishments per group w/100% frequency." Counseling: "Pt will ID 2 coping skills to maintain mood." These goals are nonspecific, are not measurable, represent staff interventions or patient tasks to complete, and do not represent patient behavioral change.

4. Patient A8's MTP, dated 4/09/10, listed the following short-term goals for problem 1, representative of all the listed problems: Physician: "Improve mood..." Social Work: "Pt will improve mood, anxiety will decrease; pt will participate in D/C planning." Nursing: "Make environment safe." Activities Therapy: "Pt will choose and complete one preferred project per group with 100& frequency." Counseling: "Pt to identify (1-3) coping skills to address depressed mood." These goals are nonspecific, are not measurable, represent staff interventions, and do not represent patient behavioral change.

5. Patient's B1's MTP, dated 3/29/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Stay safe & talk to staff daily." Social Work: "Pt will report improvement in mood & feelings ?anxiety ?hopelessness." Nursing: "Pt will have no SI and will report mood improvement." Activities Therapy: "Pt will consistently demonstrate an organized approach to task completion." Counseling: "Pt to identify (1-3) coping skills to address depressed mood." These goals nonspecific, are not measurable, and do not represent patient behavioral change.

6. Patient B6's MTP, dated 4/09/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Patient will be speaking daily for SI [sic]." Social Work: "Patient to improve mood, depression [sic]." Nursing: "Patient will have stable and improved mood without SI." Activities Therapy: "Pt will identify 1-2 leisure based activities to assist in managing feelings of depression." Counseling: "Pt will make 1-2 statements re: self worth on a daily basis." These goals are nonspecific, not measurable, and do not represent patient behavioral change.

7. Patient B7's MTP, dated 4/09/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Patient will seek for safety [sic] & talk to staff." Social Work: "Patient to improve mood." Nursing: "Patient will have stable imprvd [sic] mood or D/c without SI [sic]." Activities Therapy: "Pt will identify 1-2 leisure based activities to facilitate constructive use of time." Counseling: "Pt will make 1-2 statements re self worth on a daily basis." These goals are nonspecific, not measurable, and do not represent patient behavioral change.

8. Patient B8's MTP, dated 4/12/10, listed the following short-term goals for Problem 1, representative of all the listed problems: Physician: "Attend 3-5 AA NA groups..." Social Work: "Pt will remain sober. Pt will identify 1-3 recovery plans [sic]." Nursing: "Sube [Suboxone] detox." Activities Therapy: "Pt will identify 2 leisure based alternatives to substance abuse." Counseling: "Pt will ID 1-3 coping skills to deal with urges and cravings." These goals represent tasks to complete rather than behavioral change or are staff interventions rather than patient goals for change in behavior.

A. Staff Interview

1. In an interview on 4/12/10 at 11:30 a.m., RN2 and RN3 agreed that the treatment plans for sample patients B1, B6, B7 and B8 did not list goals which were individualized or could be used to measure patient improvement.

2. In an interview at 2:20 p.m. on 4/12/10, the Medical Director responded that the goals on the plans of B1, B6, B7 and B8 were "not really" measurable.

3. RN1 was interviewed at 9:30 a.m. on 4/13/10. The treatment plan of sample patient B6 was reviewed in detail. When asked by the surveyor if the "short-term goals" were specific to sample patient B6's needs RN1 answered "No, you can't tell."

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) that clearly delineated staff interventions to address the patients' individual problems and assist them to accomplishment their treatment objectives. Specifically, the "Interdisciplinary Treatment Plans" (MTPs) failed to:

I. Identify individualized and focused interventions to address the presenting problems and treatment goals of 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, and B8). The interventions for these patients were routine and generic tasks for various disciplines, inappropriately identified as treatment interventions.

II. Specify how interventions would be delivered (group or individual modalities) and specify the frequency of staff contact for treatment interventions for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8).

III. Include group interventions on the treatment plans that were listed on the group schedule and which were attended by 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7, and B8).

These deficiencies results in failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention prescribed by the treatment team, potentially resulting in inconsistent and/or ineffective treatment.

Findings are:

I. Failure to include individualized interventions on the MTP

A. Record Review

A review of the sample patients' "Interdisciplinary Treatment Plans" (MTPs) revealed that the plans only included routine and generic tasks for the various disciplines instead of individualized and focused interventions to assist patients accomplish their treatment goals. In addition, the listed "interventions" were often identical for patients having different presenting problems and diagnoses.

1. Patient A1's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/06/10, contained the following routine and generic discipline functions for Problem #1 "Depressed Mood":
M.D. - "Monitor & Treat psychopharm [psychopharmacology] & return to outpatient." S.W.[Social Work] - "Evaluate symptoms of depressed mood daily to assess pt's [patient's] progress in order to plan treatment. Develop 1-3 community resources [sic]."
Nursing (R.N.) - "1:1 [with] pt [patient] to assess mood/level of safety. Encourage pt [patient] to verbalize feeling/ [changes] in mood."
Therapeutic Activities (T.A.) - "Offer open Rec [recreation] 7 x per week. Support pts [patient's] feelings. Encourage pt [patient] to get attainable goals to manage symptoms of depression."
Counselor - "Explain how mental illness affects thoughts, feelings, emotions."

2. Patient A4's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/09/10, contained the following routine and generic discipline functions for Problem #1 "Depressed Mood":
M.D. - "Patient will be seen for Depression & Anxiety & see him daily."
S.W. - "Evaluate symptoms of depressed mood daily in order to monitor [sic] current stressors. Develop 1-3 community resources with pt [patient] to assist in his transition home."
Nursing (R.N.) - "Monitor mood on ? hr. [sic] med per MD orders."
Therapeutic Activities (T.A.) - Offer open Rec [recreation] 7 x per week. Validate pt's [patient's] feelings. Encourage pt [patient] to get attainable goals to manage symptoms of depression."
Counselor - "1- Facilitate reality based thinking. 2- Explain how mental illness affects thoughts, feelings, emotions. 3 - Focus on / ID positives, [sic] personal accomplishments."

3. Patient A5's "Interdisciplinary Treatment Plan," signed by the Team Leader and the Patient on 4/6/10, contained the following routine and generic discipline functions for Problem #1 "Mood Lability":
M.D. - "Patient will be seen daily and treat for mood lability."
Nursing (R.N.) - "1. Make environment safe. 2. Administer medications. 3. Group and individual pscotherapy [sic]. 4. Reality based conversation."
Therapeutic Activities (T.A.) - "Open Rec [recreation]. Encourage pt [patient] to get attainable goals to manage symptoms of depression. Support pts [patient's] feelings."
Counselor - "Explain how mental illness affects thoughts, feelings, emotions."

4. Patient A8's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/05/10, contained the following routine and generic discipline functions for Problem #1 "Depressed Mood":
Nursing (R.N.) - "1. Make environment safe. 2. Administer medications. 3. Group and individual pscotherapy [sic]. 4. Reality based conversation."
Therapeutic Activities (T.A.) - "Offer open Rec [recreation] 7x per week. Validate pt's [patient's] feelings. Praise pt [patient] [sic] verbalization of mood changes."

5. Patient B1's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 3/29/10, contained the following routine and generic discipline functions for Problem #1 "Potential for self harm r/t [related to] mood instability":
M.D. - "Monitor & Treat S/S daily & see the patient."
Nursing (R.N.) - "1:1 [with] pt [patient] to assess mood/level of safety. Encourage pt [patient] to verbalize feelings."
Therapeutic Activities (T.A.) - "Offer open Rec [recreation] 7 x per week. Encourage pt [patient] to get simple goals. Praise pt [patient] for verbalization of mood changes."

6. Patient B6's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/09/10, contained the following routine and generic discipline functions for Problem #1 "Potential for self harm r/t [related to] depressed mood":
M.D. - "Monitor & Treat S/S [signs & symptoms] while here & see him for depression." Nursing (R.N.) - "Monitor pt [patient] for safety per protocol. Medicine as ordered by MD. Encourage pt [patient] to verbalize [sic]. "
Therapeutic Activities (T.A.) - "Offer open Rec [recreation] groups daily at the hospital unit 3 x per week at the Inn. Encourage/praise pt [patient] for group participation."
Counselor - "Encourage pt [patient] to focus on positive/personal accomplishments. Explain how mental illness affects thoughts, feelings, emotions."

7. Patient B7's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/06/10, contained the following routine and generic discipline functions for Problem #1 "Potential for self harm r/t [related to] depressed Mood":
M.D. - "Monitor & Treat S/S [signs/symptoms] while seeing him daily. Talk to [sic] for SI [suicidal ideation]."
Nursing (R.N.) - "Monitor pt [patient] for safety per protocol. Medicine as ordered by MD. Encourage pt [patient] to verbalize thoughts and feelings."
Therapeutic Activities (T.A.) - "Offer open Rec [recreation] groups daily at the hospital unit and 3 x per week at the Inn. Encourage/praise pt [patient] for group participation."
Counselor - "Encourage pt [patient] to focus on positive/personal accomplishments. Explain how mental illness affects thoughts, feelings, emotions."

8. Patient B8's "Interdisciplinary Treatment Plan," signed by the Team Leader and Patient on 4/05/10, contained the following routine and generic discipline functions for Problem #1 "Potential for self harm r/t [related to] mood lability:"
S.W. - "Evaluate symptoms of depressed mood daily in order to assess current status. Develop 1-3 community supports with pt [patient] in to assist pt [patient] return to community."
Nursing (R.N.) - "1. Make environment safe. 2. Administer medications. 3. Group and individual psotherapy [sic]. 4. Reality based conversations."
Therapeutic Activities - "Offer open rec [recreation] 7 xs per week. Validate pt's [patient's] feelings. Encourage pt [patient] to get attainable goals to manage depression."

B. Staff Interviews

1. In an interview on 4/12/10 at 11:30 a.m., the treatment plans for Patients B1, B6, B7 and B8 were reviewed with RN2 and RN3 with particular attention to the nursing modalities. Both RN2 and RN3 agreed that the "interventions" listed for nurses were "basic nursing tasks" and that the MTPs did not document the frequency of the tasks to be performed.

2. In an interview on 4/12/10 at 3:10 p.m., which included a review of the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5 and A8, RN1 acknowledged that the MTPs listed routine and generic nursing functions as treatment interventions. RNI agreed that the "intervention statements" did not address the patients' presenting problems.

3. In an interview on 4/13/10 at 1:45 p.m., RN3 confirmed that routine and generic nursing functions were listed as treatment interventions on the Master Treatment Plans. RN3 agreed that the "intervention statements" did not address the patient's presenting problems.

4. In an interview on 4/13/10 at 3:45 p.m., the Director of Nursing acknowledged that statements under the section entitled "Intervention (Modalities/Frequencies)" were written as routine and generic discipline functions rather than interventions that could assist patients to accomplish their treatment goals.

II. Failure to include the Delivery Method and Frequency of Staff Contact

A. Record Review

1. Patient A1's MTP, signed by the Team Leader and Patient on 4/06/10, contained the following interventions with no specified modality or frequency of staff contact:
For Problem #1 - Depressed Mood" - Counseling: "Explain how mental illness affects thoughts, feelings, emotions."
For Problem #3 - "Medical Problems/Pain" - Counseling: "Educate pt [patient on the importance of maintaining a healthy lifestyle." Therapeutic Activities: "Educate re [regarding] benefits of maintaining a healthy lifestyle. "

2. Patient A4's MTP, signed by the Team Leader and Patient on 4/09/10, contained the following interventions with no specified modality or frequency of staff contact:
For Problem #1 - "Depressed Mood" - RN: "Educ. [educate] to coping skills. to relaxation techniques." Counseling: "Facilitate reality based thinking. Explain how mental illness affects thoughts, feelings and emotions."
For Problem #2 - "ETOH Abuse" - Therapeutic Activities - "Educate re [regarding] benefits of [sic] use of time." Counseling: "Assist pt [patient] with exploring behaviors, thoughts and feelings. Educate pt [patient on the importance of maintaining a healthy lifestyle; Assist pt [patient] with implementing positive changes in lifestyles."

3. Patient A5's MTP, signed by the Team Leader and Patient on 4/06/10, contained the following interventions with no specified modality or frequency of staff contact:
For Problem #1 - "Depressed Mood" - Counseling: "Explain how mental illness affects thoughts and emotions."
For Problem #2 - "ETOH Abuse in remission for 1? yrs" - Therapeutic Activities:
"Educate re [regarding] benefits of positive leisure activities as an alternative to S.A. [Substance Abuse]." For Problem #3 - "Medical Problem/Pain" - Social Work: "Assist patient in order to obtain the recommended treatment/follow-up." Counseling: "will educate patient on the important of maintaining a healthy lifestyle."

4. Patient A8's MTP, signed by the Team Leader and Patient on 4/05/10, contained the following interventions:
For Problem #1 - "Depressed Mood" - Counseling: "Educate Ps [patient] to express feelings in groups to address and [sic] support." Explain how mental illness affects thoughts and emotions." For Problem #2 - "Polysubstance Abuse" - Therapeutic Activities: "Educate re [regarding] benefits of constructive use of time." Counseling: "Educate Ps [sic] to benefits of 12 Steps Program, Sponsorship and Fellowship support."
For Problem #3 - "Medical Problem/Pain" - Social Work: "Assist patient in order in obtaining appropriate follow-up in order to coordinate medical needs." Therapeutic Activities: "Educate re [regarding] benefits of maintaining a healthy lifestyle." Counseling: "will educate patient on the important of maintaining a healthy lifestyle."
The intervention statement for Problem #1 did not include the frequency of contact. Intervention statements for Problems #2 and #3 did not specify whether the interventions would be delivered in group or individual sessions, nor did they include the frequency of staff contact.

5. Patient B1's MTP, signed by the Team Leader and Patient on 3/29/10, contained the following interventions:
For Problem #1 - "Potential for self harm r/t [related to] mood instability." - Counseling: "Educate Ps [sic] to express feelings in groups to address mood and garner support from grps [groups]."
For Problem #2 - "Medical Problems/Pain" - RN: "Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise [sic]." Therapeutic Activities: "Educate re [regarding] maintaining healthy lifestyle." Counseling: "Educate Ps [sic] to benefits of healthy life style and good nutrition."
The intervention statement for Problem #1 did not include the frequency of contact. The intervention statements for Problem #2 did not specify whether the intervention would be delivered in group or individual sessions, nor did it include the frequency of staff contact.

6. Patient B6's MTP, signed by the Team Leader and Patient on 4/09/10, contained the following interventions that did not specify the modality or frequency of staff contact:
For Problem #1 - "Potential for self harm r/t [related to] depressed mood" - Therapeutic Activities: "Educate re [regarding] benefits of positive leisure activities for the purpose of dealing with feelings of depression." Counseling: "Explain how mental illness affects thoughts and emotions."
For Problem #2 - "Substance Abuse" - RN: "Educate re: [regarding] relapse prevention." Therapeutic Activities: "Educate re: [regarding] importance of structured daily routine to assist with recovery/relapse prevention." Counseling: "Educate Ps [sic] on the importance of attending AA/NA, obtaining a sponsor, group therapy."

7. Patient B7's MTP, signed by the Team Leader and Patient on 4/09/10, contained the following interventions that did not specify the modality or frequency of staff contact:
For Problem #1 - "Potential for self harm r/t [related to] depressed mood" - Therapeutic Activities: "Educate re: [regarding] benefits of constructive use of time in order to deal with feelings of depression." Counseling: "Explain how mental illness affects thoughts and emotions."
For Problem #2 - "Medical Problem/Pain" - Social Work: "Assist patient in order to obtain recommended treatment and/or follow-up." Counseling: "Educate Ps [sic] on the important of maintaining a healthy lifestyle."

8. Patient B8's MTP, signed by the Team Leader and Patient on 4/12/10, contained the following interventions that did not specify the modality or frequency of staff contact:
For Problem #1 - "Potential for self harm r/t [related to] mood instability" - Counseling: "Facilitate reality based thinking. Explain how mental illness affects thoughts and emotions." For Problem #2 - "Substance Abuse" - Therapeutic Activities: "Educate re: [regarding] benefits of constructive use of time." Counselor: "1. Address today's lifestyle and how it differs from previous lifestyles. 2. Assist Ps with behaviors, thoughts, and emotions. 3. Assist Ps [sic] with implementing positive changes in lifestyle."

B. Staff Interviews

1. In an interview on 4/12/10 at 3:10 p.m., which included a review of the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5 and , A8, RN1 confirmed that plans did not specify whether the interventions would be conducted in group or individual sessions. RN1 also acknowledged that the plans failed to specify the frequency of staff contact to deliver the interventions.

2. In an interview on 4/13/10 at 3:45 p.m., the Director of Nursing acknowledged that the intervention statements under the MTP section entitled "Intervention (Modalities/Frequencies)" did not specify whether interventions would be conducted in group or individual sessions or the frequency of intervention delivery.

3. In an interview on 4/14/10 at 10:35 a.m., the Director of Substance Abuse acknowledged that intervention statements on the MTPs did not include frequency of contact, nor did they say whether the interventions would be conducted in group or individual sessions.

III. Failure to Include Groups Attended by Patients

A. The INN Building

1. Observations

a. During observations on 4/12/10 at 10:50 a.m. and 1:20 p.m. in the group room on the first floor, the surveyor observed the following groups listed on the "Group Schedule for the INN" Sample patients A1, A4, A5, and A8 attended a "12-Step Group" from 10:50 a.m. to 11:30 a.m. with 28 patients present. Sample patients A1, A4, A5 and A8 attended a group entitled "Didactic Lecture from 1:20 p.m. to 2:00 p.m. with approximately 32 patients present. These groups were not included on the sample patients' "Interdisciplinary Treatment Plans," where goals for patients attending the groups would be identified.

b. During observations on 4/13/10 at 8:50 a.m., 10:45 a.m., and 1:15 a.m. in the group room on the first floor the surveyor observed the following groups listed on the "Group Schedule for the INN." Sample patients A1, A4, A5, and A8 attended a group entitled "Group Therapy" from 8:50 a.m. to 9:15 p.m. Sample patients A1, A4, A5, and A8 attended a group entitled " Relapse Prevention" from 10:45 a.m. to 11:30 a.m. with 30 patients present. Sample patients A1, A4, A5, and A8 attended a "Medication Group" from 1:15 to 1:45 p.m. with 29 patients present. Because of the large number of patients in the room during group sessions, not all patients were able to participate. These groups were not included on the sample patients' "Interdisciplinary Treatment Plans," where goals for the patients would be identified.

2. Staff Interviews

a. In an interview on 4/12/10 at 11:40 a.m., Counselor 1 discussed treatment planning for Patient A1. She stated that she had not been attending the treatment-planning meetings, but that the 12-Step group was on the patient's treatment plan. [When the surveyor reviewed the plan for Patient A1 at 3:10 p.m., the 12-Step Group was not included on the "Interdisciplinary Treatment Plan."]

b. In an interview on 4/12/10 at 3:10 p.m., after reviewing the MTP for Patient A1 and the "Group Schedule for the Inn," RN1 confirmed that the groups on the schedule were not tied to the patient's treatment plan.

c. In an interview on 4/14/10 at 10:35 a.m. with the Director of Substance Abuse, the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5, & A8 were reviewed and compared with the group schedule. The Director of Substance Abuse acknowledged that groups attended by the patients and listed on the "Group Schedule for the Inn" were not included on each patient's treatment plan.

3. Document Review

A review of the "Group Schedule for the Inn" revealed that groups listed on the schedule and observed by the surveyor were not included on the treatment plans of Patient A1, A4, A5, or A8.

B. The UNIT Building

A. Observations

In an observation on 4/12/10 at 1:00 p.m. in the VIP Room, the Nutrition Group was in progress. The group was led by the registered dietitian. Seven (7) patients participated, including sample Patient B8. This group was on the "Group Schedule for the Unit" but not included on patient B8's "Interdisciplinary Treatment Plan."

B. Interviews

1. In an interview on 4/12/10 at 11:10 a.m., the surveyor asked Recreational Therapist RT1 how patients were selected for the "Open Recreation Group." RT1 replied "It's open to everyone...it's for the patients who can't go down to the INN" [separate building where the majority of therapeutic groups were held]. When asked how she related the Recreation Group to each individual patient's treatment goals, RT1 responded "I don't...the group helps everyone learn more effective coping skills...it's relaxing."

2. In an interview on 4/12/10 at 11:30 a.m., the treatment plans for sample patients B1, B6, B7, and B8 were discussed with RN2 and RN3. Both RN2 and RN3 acknowledged that the group therapeutic activities provided by counseling staff "are not listed on the treatment plans." They stated that they send patients to group activities on and off the unit based on "the track that the patient is assigned to." They explained that the "Track B Program Schedule" was group offerings for patients with substance abuse problems, and that the "Track C Program Schedule" group offerings were for the patients with serious psychiatric problems.

3. In an interview on 4/12/10 at 1:50 p.m. after the "Nutrition Group" session, the surveyor asked the Registered Dietitian (group leader) whether she participated in treatment planning meetings. She answered "No, I never have...if I notice something/an issue from my chart review or during the group, I bring it to the attention of the psychiatrist." When asked if she knew whether her recommendations were incorporated into the treatment plans, she answered "No, I don't."

4. In an interview with the Medical Director and Physician 1 on 4/12/10 at 2:20 p.m., the treatment plans for sample Patients B1, B6, B7, and B8 were reviewed. The absence of specific treatment modalities on the plans (including observed groups) was discussed. Both the Medical Director and Physician 1 agreed, "the groups are not listed on the plans." When the surveyor asked how the attending psychiatrists and other members of the team decide what specific groups would be best suited to address the needs of a particular patient, the Medical Director and Physician 1 stated "the patients are assigned to tracks" based on whether they are confined to their units or can leave their units, not to specific groups based on need.
5. In an interview with sample patient B6 on 4/13/10 at 9:00 AM, about treatment planning. The patient could not state an understanding of what the focus of his treatment would be and what specific therapeutic groups were being recommended to him. He said "...The staff just tell us when there's going to be a group." When asked if he came away from the planning meeting, knowing how often his doctor and his social worker would be meeting with him, he stated "No."

C. Document Review

A review of the "Group Schedule for the Unit" revealed that the groups listed on the schedule and observed by the surveyor were not included on the treatment plans of Patient B1, B6, B7 and B8.

Based on record review and interview, the facility failed to ensure that the patient's responses to interventions listed on the "Interdisciplinary Treatment Plans" were documented. Specifically, there was no documentation in the medical records or on "Group Evaluation Forms" regarding the patient's attendance, topics discussed, and/or the patient's responses to the intervention (level of participation and understanding) by Registered Nurses for 3 of 8 active sample patients (A4, B1, and B6); by Therapeutic Activities staff for 4 of 4 active sample patients (A1, A4, A5, and A8) at the INN (a three story structure with a 39 bed capacity), and by Counseling staff for 4 of 4 active sample patients (B1, B6, B7, and B8) at the UNIT (a one story structure with a 20 bed capacity). This failure hampers the treatment team's ability to determine patients' responses to treatment interventions and revise the treatment plan as needed.

Findings are:

A. Record Review

1. Patient A1's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/06/10, for Problem #3 ("Medical Problems/Pain") contained the following intervention for Therapeutic Activities: "Educate re [regarding] benefits of maintaining a healthy lifestyle." There was no documentation in the medical record or on the "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

2. Patient A4's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/09/10, contained the following problems and interventions:
For Problem #1 - "Depressed Mood" - RN: "Educ. [educate] to coping skills. [sic] to relaxation techniques."
For Problem #2 - "ETOH Abuse" - Therapeutic Activities - "Educate re [regarding] benefits of constructive use of time."
There was no documentation in the medical record or on "Group Evaluation Forms" reflecting the topic discussed and patient's response, including level of participation and understanding.

3. Patient A5's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/06/10, for Problem #2 - "ETOH Abuse in remission for 1? yrs" - contained the intervention for Therapeutic Activities: "Educate re [regarding] benefits of positive leisure activities as an alternative to S.A. [Substance Abuse]." There was no documentation in the medical record or on "Group Evaluation Forms" reflecting the topic or the patient's response, including level of participation and understanding.

4. Patient A8's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/05/10, contained the following problems and interventions:
For Problem #2 - "Polysubstance Abuse" - Therapeutic Activities: "Educate re [regarding] benefits of constructive use of time."
For Problem #3 - "Medical Problem/Pain" - Therapeutic Activities: "Educate re [regarding] benefits of maintaining a healthy lifestyle."
There was no documentation in the medical record or on "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

5. Patient B1's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 3/29/10, contained the following problems and interventions: Problem #2 - "Medical Problems/Pain" - RN: Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise [sic]." Therapeutic Activities: Educate re [regarding] maintaining healthy lifestyle." Counseling: "Educate Ps [sic] to benefits of healthy life style and good nutrition."
There was no documentation in the medical record or on "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

6. Patient B6's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/09/10, contained the following problems and interventions:
For Problem #1 - "Potential for self harm r/t [related to] depressed mood" - Therapeutic Activities: "Educate re [regarding] benefits of positive leisure activities for the purpose of dealing with feelings of depression." Counseling: "Explain how mental illness affects thoughts and emotions."
For Problem #2 - "Substance Abuse" - RN: Educate re: [regarding] relapse prevention." Therapeutic Activities: Educate re: [regarding] importance of structured daily routine to assist with recovery/relapse prevention."
There was no documentation in the medical record or on "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

7. Patient B7's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/09/10, contained the following problem and interventions: Problem #1 - "Potential for self harm r/t [related to] depressed mood" - Therapeutic Activities: "Educate re: [regarding] benefits of constructive use of time in order to deal with feelings of depression." Counseling: "Explain how mental illness affects thoughts and emotions."
There was no documentation in the medical record or "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

8. Patient B8's "Interdisciplinary Treatment Plan," signed by Team Leader and Patient on 4/12/10, contained the following problems and interventions:
For Problem #1 - "Potential for self harm r/t [related to] mood instability" - Counseling: Explain how mental illness affects thoughts and emotions."
For Problem #2 - "Substance Abuse" - Therapeutic Activities: "Educate re: [regarding] benefits of constructive use of time."
There was no documentation in the medical record or "Group Evaluation Forms" reflecting the topic discussed or the patient's response, including level of participation and understanding.

B. Staff Interviews

1. In an interview on 4/13/10 at 1:45 p.m., RN3 acknowledged that the intervention related to education was not documented in the Nursing Notes for Patient A4.

2. In an interview on 4/13/10 at 11:30 a.m., the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5 and A8 were reviewed with the Director of Therapeutic Activities (TA). The TA Director stated that the interventions listed and conducted by the Therapeutic Activities staff were documented on the "Group Evaluations Form." He was unable to locate documentation by Therapeutic Activities staff regarding interventions related to patient education as outlined on the patients' "Interdisciplinary Treatment Plan."

3. In an interview on 4/14/10 at 11:00 a.m., RN1 and the surveyor reviewed the nursing progress notes for sample Patients B1 and B6.
The treatment plan for Patient B1 stated that, for problem #1, nursing would provide 1:1 contact with B1 "to assess mood and level of safety" and, for problem #2, nursing would "Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise." RN2 confirmed that there were no nursing notes indicating that these interventions had occurred over B1's length of stay to the date of the survey.
The treatment plan for Patient B6 stated that for problem #1, nursing staff would "monitor pt for safety per protocol" and "encourage pt to verbalize thoughts and feelings. For problem #2, nurses were to "Educate pt [patient] re: [regarding] relapse prevention," and for problem #3, they were to "Educate pt re healthy lifestyle choices." RN1 confirmed that there were no nursing notes regarding these interventions in B6's record; she stated "[there are] just shift notes."

Based on record review and staff interview, the facility failed to ensure proper documentation of seclusion and restraint procedures for 1 of 1 non-sample patients (B10) chosen for review of seclusion and restraint procedures. Specifically, in 6 restraint episodes that occurred between 4/03/10 and 4/10/10, the physician's assessment within one hour was not properly documented. It was not documented or documented late in 4 instances. In addition, the signature with date and time of the physician authorizing the release from restraint was not documented in 4 instances, as the form requires. In addition, two restraint orders were written as "prn" orders. These failures expose patients to potential harm from unnecessary seclusion or restraint, and violate patients' rights to be free from restraint except to prevent immediate harm to self or others.

Findings are:

Record Review

1. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/03/10 with a start time 2:35 PM: no date or time of examination by MD recorded.

2. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/04/10 with a start time 2:45 AM: MD signature indicates the physician did not examine the patient until 10:33 AM, some 8 hours after the initiation of the restraint episode.

3. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/09/10 with a start time 2:45 PM: there is no signature of either a physician or a nurse authorizing the release from restraint.

4. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/09/10 with a start time 2:51 PM: there is no signature of either a physician or a nurse authorizing the release from restraint.

5. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/09/10 with a start time 10:00 PM: no date or time of examination by MD recorded; there is no signature of either a physician or a nurse authorizing the release from restraint.

6. Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06: Restraint episode of 4/10/10 without a start time or an end time: the time that the physician examined the patient is not recorded; there is no signature of either a physician or a nurse authorizing the release
from restraint.

7. Restraint order of 4/03/10 written at 3:40 AM: "4 pt [point] restraints if needed NTE [not to exceed] 2 hrs protection Self/others [sic]"

8. Restraint order of 4/04/10 written at 3:30 AM: "4 pt restraints if needed to hold for IM [intramuscular] ativan [sic] protection self & others [sic]" Of note, the order is not signed off by a nurse.

B. Staff Interview

In an interview on 4/14/10 at 10:15 a.m., RN1 looked at the orders of 4/03/10 and 4/04/10 with the surveyor. RN1 stated, "yes, the orders say 'if needed.'" The Emergency Restraint or Seclusion (R/S) Form - Part A - Revised 4/06 forms also was reviewed; RN1 agreed that required physician documentation was missing and stated "there are missing physician assessments on multiple episodes."

Based on record review and interview, the facility failed to ensure that attending psychiatrists completed discharge summaries that included detailed information regarding the rationale for and course of treatment during hospitalization for 5 of 5 discharged records reviewed (C1-C5). 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 individual patients.

Findings are:

A. Record Review

1. Patient C1 was admitted 2/28/10 and discharged 3/04/10. There was no summary of the circumstances and rationale for admission. The Discharge Summary stated, "Presenting problems and present illness are detailed in the Admission History and Physical on file." There was no summary of treatment interventions implemented or the patient's response except for pharmacology, laboratory findings, and alcohol detox protocol.

2. Patient C3 was admitted 3/1/10 and discharged 3/5/10. There was no summary of the circumstances and rationale for admission. The Discharge Summary stated, "Presenting problems and present illness are detailed in the Admission History and Physical on file." There was no summary of treatment interventions implemented and the patient's response except for pharmacology and laboratory findings.

3. Patient C4 was admitted 3/5/10 and discharged 3/12/10. There was no summary of the circumstances and rationale for admission. The Discharge Summary documented, "Presenting problems and present illness are detailed in the Admission History and Physical on file." There was no summary of treatment interventions implemented or the patient's response except for pharmacology, laboratory findings, and Suboxone detoxification protocol.

4. Patient C5 was admitted 3/6/10 and discharged 3/13/10. There was no summary of the circumstances and rationale for admission. The Discharge Summary stated, "Presenting problems and present illness are detailed in the Admission History and Physical on file." There was no summary of treatment interventions implemented and the patient's response except for pharmacology and laboratory findings.

B. Document Review

The "Professional Staff Meeting" minutes dated 7/29/09 noted, "The status of the medical records was discussed at length; discharge summaries have significant gaps, and the doctors have been given verbal warning that these must be completed."

C. Staff Interview


In an interview on 4/13/10 at 10:05 a.m., the surveyor and the Medical Director reviewed the 5 sample discharge summaries, looking at content relative to the standards. The Medical Director stated, "Yes, I see that these elements are not included."

Based on record review and interview, the facility failed to describe arrangements in effect on the day of discharge for follow-up community-based services and supports appropriate to the needs of 2 of 5 discharged records reviewed (C1 & C2). Information regarding appointment dates, times, names and/or phone contacts was not documented in the discharge instructions. This failure requires patients or their families to negotiate appointments with agencies or physician offices, and may result in incomplete and inconsistent aftercare treatment.

Findings are:

A. Record Review

1. Patient C1

The patient was discharged on 3/04/10. The physician's discharge summary dictated on 3/25/10 stated, "The patient will be going back to Maine where she will seek psychiatric care. Meanwhile, the patient will return to [MD's name] in... Peabody, Massachusetts. The "Discharge Instructions" completed by social services contained the staff signature however had no date indicating when the form was signed. The information under aftercare was blank. For psychiatrist, it stated, "Pt [patient] is moving to Maine and will follow up on own."

2. Patient C2

The patient was discharged on 3/05/10. The physician's discharge summary dictated on 3/19/10 stated, "The patient will be returning as scheduled to his primary care physician and [name of] Community Mental Health. The patient will see [MD's name] as scheduled." The "Discharge Instructions" completed by social services contained the staff signature however had no date indicating when the form was signed. The information under Psychiatrist and Therapist stated "To be scheduled by PCP [Primary Care Physician]."

B. Staff Interview

1. During a discussion with the surveyor on 4/14/10 at 10:50 a.m., Social Worker 1 stated that since Patient C1 was moving out of state, the patient sets up the aftercare appointment. For Patient C2, Social Worker 1 stated if new to the community mental health center, the Primary Care Physician has to schedule the appointment for the patient.

2. An interview was conducted with the Medical Director on 4/13/10 at 10:05 a.m. The surveyor and the Medical Director reviewed the 5 sample discharge summaries, looking at the content relative to the standards. The Medical Director stated, "Yes, I see that these elements are not included."

Based on record review and interview, the facility's Medical Director failed to:

I. Ensure that the psychiatric evaluations of 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) contained sufficient documentation of specific signs, symptoms, precipitating factors, and course of illness to justify the diagnosis/es that formed the basis for the proposed treatment. Failure to provide the necessary information to justify the diagnosis impedes the treatment team's ability to formulate a meaningful plan of care designed to meet the patient's individual needs. (Refer to B110)

II. Ensure that the psychiatric evaluations of 5 of 8 sample patients (A1, A5, A8, B1, and B7) included an inventory of the patient's assets in a descriptive, not interpretive fashion. Failure to describe those personal factors, strengths, and/or attributes with which the patient presents compromises the treatment team's ability to develop a meaningful treatment plan and limits the team's ability to engage the patient in therapy. (Refer to B117)

III. Ensure that the Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) were comprehensive (contained all appropriate elements to guide staff in providing optimal treatment). Specifically, the facility failed to provide MTPs that included:
1) an inventory of patient strengths and disabilities (Refer to B119);
2) substantiated diagnosis (Refer to B120);
3) individualized short-term goals, described in observable and/or measurable terms, and not expressed as staff goals (Refer to B 121); and
4) individualized treatment modalities (Refer to B122).

Failure to develop Master Treatment Plans that contain all appropriate elements to guide staff in providing treatment (i.e. substantiated diagnoses, individualized and measurable short-term goals, and individualized treatment modalities) compromises the team's ability to effectively address the patients' problems and to meet the patients' needs for successful and timely return to the community.

IV. Ensure proper documentation of seclusion and restraint procedures for 1 of 1 non-sample patients (B10) chosen for review of seclusion and restraint procedures. Specifically, over 6 restraint episodes that occurred between 4/03/10 and 4/10/10, the physician's assessment within one hour was not documented or documented late in 4 instances, and the signature with date and time of the physician authorizing the release from restraint was not documented in 4 instances. These failures expose patients to potential harm from unnecessary seclusion or restraint, and violate patients' rights to be free from restraint except to prevent immediate harm to self or others. (Refer to B125)

V. Ensure that attending psychiatrists completed discharge summaries that included detailed information regarding the rationale for and course of treatment during hospitalization for 5 of 5 discharged records reviewed (C1-C5). 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 individual patients. (Refer to B133)

Findings are:

Staff interview

In an interview on 4/14/10 at 10:05 a.m., the Medical Director asked for the web address for the CMS standards related to Psychiatric Hospitals, indicating that he would find this helpful. He acknowledged his "lack of familiarity" with the CMS standards and how this impeded his ability to ensure the quality of documentation required of the facility's physicians.

Based on observation, record review, and interview, the Director of Nursing (DON) failed to:

I. Ensure that "Interdisciplinary Treatment Plans" (MTPs) for 8 of 8 active sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) contained nursing group and individual active treatment measures that addressed patients' individualized presenting problems and treatment goals. The MTPs included routine and generic nursing functions, inappropriately listed as treatment interventions.

II. Ensure that "Interdisciplinary Treatment Plans" (MTPs) specified how nursing interventions would be delivered (group or individual sessions) and included the frequency of contacts for treatment for 3 of 8 sample patients (A4, B1 and B6).

The deficiencies in I & II result in lack of guidance to nursing staff in providing care, potentially resulting in inconsistent and/or ineffective treatment.

III. Ensure that the patient's responses to nursing interventions listed on the "Interdisciplinary Treatment Plans" were documented. Specifically, there was no documentation in the medical record or on "Group Evaluation Forms" regarding the patient's attendance, topics discussed, and/or the patient's responses to the intervention (level of participation and understanding) by Registered Nurses for 3 of 8 active sample patients (A4, B1, and B6). This failure potentially hampers the treatment team's ability to determine patients' responses to treatment interventions and revise the treatment plan as needed.


Findings are:

I. Failure to ensure individualized nursing interventions

A. Record Review

A review of medical records for the sample patients revealed that the "Interdisciplinary Treatment Plans" (MTP dates in parentheses) contained routine and generic nursing tasks instead of individualized interventions to assist patients accomplish their treatment goals. The "intervention statements" also were identical or very similar for all patients.

1. Patient A1's "Interdisciplinary Treatment Plan," (4/06/10) contained the following routine generic nursing task for Problem #1 "Depressed Mood": "1:1 [with] pt [patient] to assess mood/level of safety. Encourage pt [patient] to verbalize feeling/[changes] in mood."

2. Patient A4's "Interdisciplinary Treatment Plan," (4/09/10), contained the following routine and generic nursing task for Problem #1 "Depressed Mood": "Monitor mood on ? hr. [sic] med per MD orders."

3. Patient A5's "Interdisciplinary Treatment Plan," (4/06/10) contained the following routine and generic nursing task for Problem #1 "Mood Lability": "1. Make environment safe. 2. Administer medications. 3. Group and individual pscotherapy [sic]. 4. Reality based conversation."

4. Patient A8's "Interdisciplinary Treatment Plan" (4/05/10) contained the following routine and generic nursing tasks for Problem #1 "Depressed Mood": "1. Make environment safe. 2. Administer medications. 3. Group and individual pscotherapy [sic]. 4. Reality based conversation."

5. Patient B1's "Interdisciplinary Treatment Plan" (3/29/10) contained the following routine and generic nursing tasks for Problem #1 "Potential for self harm r/t [related to] mood instability": "1:1 [with] pt [patient] to assess mood/level of safety. Encourage pt [patient] to verbalize feelings."

6. Patient B6's "Interdisciplinary Treatment Plan" (4/09/10) contained the following routine and generic nursing tasks for Problem #1 "Potential for self harm r/t [related to] depressed mood": "Monitor pt [patient] for safety per protocol. Medicine as ordered by MD. Encourage pt [patient] to verbalize [sic]."

7. Patient B7's "Interdisciplinary Treatment Plan" (4/06/10) contained the following routine and generic nursing tasks for Problem #1 "Potential for self harm r/t [related to] depressed Mood": "Monitor pt [patient] for safety per protocol. Medicine as ordered by MD. Encourage pt [patient] to verbalize thoughts and feelings."

8. Patient B8's "Interdisciplinary Treatment Plan" (4/05/10) contained the following routine and generic nursing tasks for Problem #1 "Potential for self harm r/t [related to] mood lability": "1. Make environment safe. 2. Administer medications. 3. Group and individual psotherapy [sic]. 4. Reality based conversations."

B. Staff Interviews

1. In an interview on 4/12/10 at 3:10 p.m., after reviewing the "Interdisciplinary Treatment Plan" for Patients A1, A4, A5 and A8, RN1 acknowledged that routine and generic nursing tasks listed as treatment interventions did not address the patient's needs identified in the nursing and other clinical assessments.

2. In an interview on 4/13/10 at 1:45 p.m., RN3 confirmed that routine and generic nursing functions were listed as treatment interventions on the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5 and A8.

3. In an interview on 4/13/10 at 3:45 p.m., the Director of Nursing acknowledged that the statements for "Intervention (Modalities/Frequencies)" on the treatment plans were routine and generic nursing tasks rather than individualized interventions to assist patients accomplish their treatment goals.

II. Failure to specify the modality and frequency of nursing interventions.

A. Record Review

1. Patient A4's, "Interdisciplinary Treatment Plan" (4/09/10) contained the following nursing intervention: Problem #1 - "Depressed Mood" - RN: "Educ. [educate] to coping skills. to relaxation techniques[sic]." This intervention statement did not specify whether interventions would be delivered in group or individual sessions nor include the frequency of contact.

2. Patient B1's "Interdisciplinary Treatment Plan" (3/29/10) contained the following nursing intervention: Problem #2 - "Medical Problems/Pain" - RN: Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise [sic]." This intervention statement did not specify whether intervention would be delivered in group or individual sessions nor include the frequency of contact.

3. Patient B6's "Interdisciplinary Treatment Plan" (4/09/10) contained the following nursing intervention: Problem #2 - "Substance Abuse" - RN: Educate re: [regarding] relapse prevention." This intervention statement did not specify whether interventions would be delivered in group or individual sessions nor include the frequency of contact.

B. Staff Interviews

1. In an interview on 4/12/10 at 3:10 p.m., after reviewing the "Interdisciplinary Treatment Plans" for Patients A1, A4, A5 and A8, RN1 confirmed that nursing intervention statements did not specify whether interventions would be conducted in group or individual sessions. RN1 also acknowledged that the frequency of contact was not included for the interventions.

2. During interview on 4/13/10 at 3:45 p.m., the Director of Nursing acknowledged that nursing intervention statements on the master treatment plan did not specify whether the interventions would be conducted in group or individual sessions, nor did they specify how often the interventions would be delivered. She noted the section on the treatment plan entitled "Intervention (Modalities/Frequencies)" required the nurse to indicate the frequency of interventions, but this was not done.

III. Failure to document active treatment measures by nurses

A. Record Review

1. Patient A4's "Interdisciplinary Treatment Plan" (4/09/10) contained nursing interventions for the following problems that were not documented in the medical record or on "Group Evaluation Forms" as being conducted or not conducted. Problem #1 - "Depressed Mood" - RN: "Educ. [educate] to coping skills. to relaxation techniques [sic]." There was no documentation regarding the topics discussed or the patient's response to the interventions.

2. Patient B1's "Interdisciplinary Treatment Plan" (3/29/10) contained nursing interventions for the following problems that were not documented in the medical record or on "Group Evaluation Forms" as being conducted or not conducted. Problem #2 - "Medical Problems/Pain" - RN: "Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise [sic]." There was no documentation regarding the topics discussed or the patient's response to the intervention.

3. Patient B6's "Interdisciplinary Treatment Plan" (4/09/10) contained nursing interventions for the following problems that were not documented in the medical record or on "Group Evaluation Forms" as being conducted or not conducted. Problem #2 - "Substance Abuse" - RN: Educate re: [regarding] relapse prevention." There was no documentation regarding the topic discussed or the patient's response to the intervention.

B. Staff Interviews

1. In an interview on 4/13/10 at 1:45 p.m., RN3 acknowledged that the nursing intervention on the treatment plan stating, "Educ. [educate] to coping skills to relaxation techniques [sic]" was not documented in the medical record for Patient A4.

2. In an interview on 4/14/10 at 11:00 a.m., RN1 and the surveyor reviewed the treatment plans and nursing progress notes for sample Patients B1 and B6.
The treatment plan for B1 stated that for problem #1, nursing would provide "1:1 contact" with B1 "to assess mood and level of safety." For problem #2, nurses were to "Educate pt [patient] re: [regarding] benefits of well balanced diet/exercise." RN2 confirmed that there were no nursing notes documenting whether these interventions had occurred over B1's length of stay to-date.

The treatment plan for B6 stated that for problem #1, nursing staff would "monitor pt for safety per protocol" and "encourage pt to verbalize thoughts and feelings." For problem #2, nurses were to "Educate pt [patient] re: [regarding] relapse prevention." For problem #3, nurses were to "Educate pt re healthy lifestyle choices." RN1 confirmed that there were no nursing notes regarding these interventions in B6's record. There were "just shift notes."

Based on observations, record review, and interviews, it was determined that the facility failed to deploy adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Mental Health Associates (MHAs) to provide nursing care, supervise, and monitor patients. Registered Nurses workload on the day and evening shifts required them to spend most of their time in the Nursing Station completing admissions, discharges, and other clinical paperwork. Additionally, on the night shift at the INN, with no nurse present, certified patients housed on the first floor were left unsupervised when MHAs were completing checks on the second and third floors, which did not have certified beds.

This staffing pattern results in the lack of involvement by RNs in active treatments measures outlined on the MTPs, lack of supervision of patients by nursing staff, and lack of direction and supervision of MHAs assigned to monitor patients.

Findings are:

A. Observations

The RN Surveyor conducted observations in the Nursing Station area at the INN on 4/12/10 (2:30 p.m.-- 4:00 p.m.), 4/13/10 ( 9:30 a.m.- 10:30 a.m.; 2:00 p.m.--3:30 p.m.), and on 4/14/10 (10:15 a.m.--11:30 a.m.) On 4/13/10, the RN covering the night shift stayed until approximately 11:30 a.m. to assist because she said "it is so busy." The observations revealed that registered Nurses' (RN) duties included completing nursing assessments, admitting and discharging patients, attending treatment planning meetings, charting nursing notes, handling emergencies, assisting physicians, and therapists, and answering phones. Licensed Practical Nurses (LPN) duties were administering medications, transcribing and charting medications orders. These duties required the licensed staff to remain in the nursing stations most of the time.

B. Document Review

1. The INN Building

The INN was a three-story structure without an elevator. The first floor of the INN building housed the certified beds (10) where the group and dining rooms were located. The Nursing Station and Charting Room were located on the second floor. Non-certified beds were located on the second and third floor with 19 and 10 beds respectively.

a. An analysis of the staffing data for 4/12/10 revealed the INN had a census of 33 patients (9 certified and 24 non-certified patients). The staff for INN was assigned to cover the certified and non-certified patients. This staffing was as follows:

Day Shift - The staffing included one RN who worked 8 hours and one RN who worked from 12 noon to 8:00 p.m. covering 4 hours on the day shift. This RN floated between the INN and the UNIT (approximately 1 mile away). There was one LPN and there were three MHAs.

Evening shift - The staffing included one RN who worked 8 hours and 1 RN from the day who worked from 12 Noon to 8:00 p.m. covering 4 hours on the evening shift and floated between the INN and UNIT. There were 3 MHAs.

Night Shift - The staffing was one RN and 2 MHAs.

b. A review of staffing for a one-week period (4/04/10 - 4/10/10) revealed a similar census and staffing. The census ranged from 25 to 38 patients (certified and non-certified) with staffing as follows:

Day shift - 1.75 RNs and 1 LPN for three of five weekday shifts, 2.75 RNs and no LPN for two of five weekday shifts. The ".75" RNs in the staffing pattern during the week included the one RN who worked from 12 Noon to 8:00 p.m. covering 4 hours on the day shift, and floated between the INN and the UNIT (approximately 1 mile away) to assist with admissions and discharges. The Director of Nursing reported that the day supervisor also provided some direct care and floated between the INN and UNIT, and so was included in the ".75". The coverage for the weekend was 1 RN and 1.5 LPNs on Sunday and 2.5 RNs on Saturday. There were 3 to 3.5 MHAs assigned on the day shift each day.

Evening shift - 1.75 RNs and 1 LPN for three of five weekday shifts, 2.75 RNs and no LPN for two of five weekday shifts. The ".75" RNs in the staffing pattern during the week included the same RN from the day shift who worked from 12 Noon to 8:00 p.m. covering 4 hours on the evening shift. This RN floated between the INN and the UNIT (approximately 1 mile away) to assist with admissions and discharges. The Director of Nursing reported that the evening supervisor also provided direct care and floated between the INN and UNIT. The coverage for the weekend was 1.5 RNs and 1 LPN Sunday and Saturday. There were 3 MHAs assigned on the evening shift.

Night shift - 1 RN and 2 MHAs for seven of seven shifts. [If a patient incident were to occur, there would be insufficient staff available to handle the incident and supervise other patients.]

c. Review of needs assessment data for the INN revealed the following:

On 4/12/10, the RN completed one admission assessment and 4 discharges on the day shift. The RN on the evening shift completed two admission assessments and one discharge. The average number of admissions per week for the INN was 7.6 on the day shift, 18.7 on the evening shift, and 4.7 on the night shift. The average number of discharges weekly was 2.9 on the day shift and 2 on the evening shift. The average weekly transfers (primarily to the UNIT) were 5.4 on the day shift and 8 on the evening shift. On 4/12/10, there were 11 patients on Detox Protocol, 2 on Diabetic checks, and 12 patients admitted within the previous 48 hours. This nursing needs assessment data revealed an extremely heavy workload for the licensed nursing staff. This required the RNs to stay in the Nurseing Station to process paperwork associated with admissions, discharges, and other clinical issues, resulting in the lack of contact with patients not being admitted or discharged, and lack of supervision of MHAs assigned to monitor patients, leading to an unsafe environment and representing a risk for patient safety. The large number of patients on Detox required the LPN assigned to Medication to also spend most of her time in the Nursing Station administering medications related to Detox as well as regular medications for 33 patients on the day of the survey.

2. The UNIT Building

The Unit was a one-story structure with a capacity for 20 certified beds.

a. An analysis of the staffing data for 4/12/10 revealed that the UNIT had a census of 15 patients. The staffing was as follows:

Day Shift - The staffing included one RN who worked 8 hours on the day shift and one RN who worked from 12 Noon to 8:00 p.m., covering 4 hours on the day shift. This RN floated between the INN and the UNIT buildings. The staffing included one LPN, and three MHAs.


Evening shift - The staffing included one RN who worked 8 hours on the evening shift and the 1 RN from the day shift who worked from 12 Noon to 8:00 p.m., covering 4 hours on the evening shift. This RN floated between the INN and the UNIT buildings. The staffing included 3 MHAs.


Night Shift - The staffing included one RN and 3 MHAs.

b. A review of staffing for a one-week period (4/04/10 - 4/10/10 revealed similar census and staffing. The census ranged from 9 to 14 patients with staffing as follows:

Day shift - 1.75 RNs and 1 LPN for two of five weekday shifts, 2.75 RNs and no LPNs for three of five weekday shifts. The ".75" RNs in the staffing pattern during the week included one RN who worked from 12 Noon to 8:00 p.m. covering 4 hours on the day shift. This RN floated between the INN and the Unit (approximately 1 mile away) to assist with admissions and discharges. The Director of Nursing reported that the day supervisor also provided some direct care and floated between the INN and UNIT. The coverage for the weekend was 1 RN and 1.5 LPN on Sunday and 2.5 RN on Saturday. There were 3 to 3.5 MHAs assigned on the day shift each day.

Evening shift - 1.75 RNs and 1 LPN for two of five weekday shifts, 2.75 RNs and no LPN for three of five weekday shifts. Weekend staffing included 2.5 RNs and no LPN on Sunday and Saturday. The ".75" RNs in the staffing pattern during the week included the same RN from the day shift who worked from 12 Noon to 8:00 p.m. covering 4 hours on the evening shift. This RN floated between the INN and the UNIT (approximately 1 mile away) to assist with admissions and discharges. The Director of Nursing reported that the evening supervisor also provided some direct care and floated between the INN and UNIT. The coverage for the weekend was 2.5 RNs on Sunday and Saturday. There were 3 MHAs assigned on the evening shifts.

Night shift - 1 RN and 3 MHAs for seven of seven shifts.

c. Review of needs assessment data for the UNIT revealed the following:

On 4/12/10, the RN on the day shift completed one admission assessment. The average number of admissions per week for the Unit was 3.5 on the day shift, 8 on the evening shift, and 2 on the night shift. The average number of discharges was 9 weekly on the day shift. On 4/12/10, there were 4 patients on Detox Protocols, 3 on Diabetic checks, and 5 patients admitted within the previous 48 hours.

On 4/12/10, psychiatric nursing care problems included 1 potentially assaultive patient, one actively assaultive patient, two patients who were experiencing active hallucination and delusions, and 1 patient who had been secluded during the previous 48 hours. These patients required close monitoring by nursing staff.

This nursing needs data revealed a workload that required the RN to spend a lot of time processing paperwork associated with admissions, discharges and other clinical issues, resulting in the potential for lack of contact with those patients not being admitted or discharged, and lack of supervision of patients and of MHAs who were assigned to monitor patients.

B. Staff Interviews

1. In an interview on 4/13/10 at 10:20 a.m.at the INN, RN4 stated that the two MHAs on the night shift "are not posted on the floors with patients but they are always moving around." She acknowledged that a staff might not always be available for patients on each of the floors.

2. In an interview on 4/13/10 at 3:45 p.m., the Director of Nursing confirmed that licensed nursing staff spends most of their time in the Nursing Station due to the number of admissions, discharges, and amount of paper work required. When asked about why there was no regular RN who worked 8 hours on the day shift or evening shift assigned to the INN and UNIT, she said RNs rotated between the INN and the UNIT to prevent "burnout." She noted that these RNs had requested to rotate off the INN to avoid "burnout."

3. In an interview on 4/14/10 at 11:50 a.m., RN5 acknowledged that the RNs spent most of their time in the Nursing Station doing admissions, discharges, and paperwork. She stated, "I prefer to be the Medication Nurse because I have more contact with patients and can chart more information about the patient." She said, "nurses use to have more time to resolve issues like patient complaints."

4. During a discussion about staffing on the UNIT on 4/14/10 at 12:15 p.m., RN1 acknowledged that they could use more staffing. RN1 confirmed spending a lot time on the second floor in the Nursing Station when working at the INN on 4/12/10.


A. Document Review


1. A review of the "Baldpate Hospital Nursing Consultation" minutes revealed the following notations:


a. [1/27/10]: "Met with [DON] and [staff name] a social worker at Baldpate. She [social work from the INN] voiced her concerns about sexually inappropriate behavior of patients. There is always a concern about this behavior due to the population served and the physical layout at the Residential Inn. [Staff name] questioned about the need for more specific guidelines to be given to patients...The responsibility does fall with the staff to carefully monitor patients; however, patients generally can find ways to participate in this type of behavior regardless of any supervision."


b. [3/3/10]: "One significant issue is the overtime on the night shift. There has [sic] been several sick calls on this shift, and off shift nurses have needed to cover, leaving open [sic] on the other shifts. Met with [staff name] and [DON] regarding U.R. [Utilization Review]. There are some missing nurses notes that [staff name] is following up. Specific areas are times of treatments, follow-up with patient complaints and shift notes incomplete."


2. A review of "Incident/Accident Reports" for the facility revealed the following incidents:


a. [3/3/10 - 5:00 a.m.]: "Pt [patient] agitated, anxious, yelling, screaming, began to punch self in face. Per pt [patient] request - MHAs held arms..."

b.[3/24/10 - no time of incident documented]: "Pt [patient's] roommate reported to Nursing Station that pt [patient] on bedroom floor - Pt [patient] upon Assessment [sic] - on left side of bed on floor reported he rolled out of bed. Assisted to chair with 2 staff. Reports pain at hip [sic]." Physician notified at 10:15 p.m.

3. A review of a "Resolution of Complaint" dated 3/31/10 revealed the following notation: "Client reported to MHA and Nursing staff on the morning of 3/20/2010 as noted by [night nurse's name at the INN] in the nursing notes that an unnamed male patient had been knocking on his bedroom door and asking for sexual favors...According to [Patient's name], said male patient during the 20th and the 21st continued to harass client for sexual favors and escalated on the evening shift when client was cornered in the stairwell corridor by said male patient. Client reported being very threatened and was able to get out of the situation, when said patient, showed up at his bedroom door and exposed himself to the client and wanting sexual favors..." The conclusion of the report said, "...Client's complaint appears valid in regards to sexual harassment and indecent exposure."

4. A review of the medical record revealed that RNs failed to document the patient's responses to active treatment interventions stipulated on the "Interdisciplinary Treatment Plan. There was no documentation regarding these sessions being were held or not held and no documentation regarding the patient's responses to nursing interventions for 3 of 8 active sample patients (A4, A5, & B6). ( Refer to B124)

Based on record review and interview, the facility's Director of Social Work failed to:

I. Ensure that the social work assessments for 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) included recommendations regarding the role of the social worker in treatment and discharge planning, and specified the community resources and support systems needed for effective discharge of the patient. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient's discharge plan, ensuring safe re-entry into the community. (Refer to B108)

II. Ensure that the short-term goals for social work interventions listed on the Interdisciplinary Treatment Plans of 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7, and B8) were individualized for patients and were measurable. Failure to document individualized and measurable patient goals for social work interventions compromises the social worker's ability to provide effective treatment and develop meaningful discharge plans to prepare the patient for successful re-entry into the community.

1. Patient A1's MTP, dated 4/06/10, listed the short-term goal for the social work intervention as "Pt will improve depressed mood...will develop 1-3 community resources"

2. Patient A4's MTP, dated 4/09/10, listed the short-term goal for the social work intervention as "Pt will improve depressed mood; pt will develop 1-3 community resources"

3. Patient A5's MTP, dated 4/07/10, listed the short-term goal for the social work intervention as "Patient to improve mood"

4. Patient A8's MTP, dated 4/09/10, listed the short-term goal for the social work intervention as "Pt will improve mood, anxiety will decrease; pt will partipate in D/C planning"

5. Patient B1's MTP, dated 3/29/10, listed the short-term goal for the social work intervention as "Pt will report improvement in mood & feelings, ?anxiety ?hopelessness"

6. Patient B6's MTP, dated 4/09/10, listed the short-term goal for the social work intervention as "Patient to improve mood, depression [sic]"

7. Patient B7's MTP, dated 4/09/10, listed the short-term goal for the social work intervention as "Patient to improve mood"

8. Patient B8's MTP, dated 4/12/10, listed the short-term goal for the social work intervention as "Pt will remain sober"


III. Ensure that the interventions for social workers listed on the Interdisciplinary Treatment Plans of 8 of 8 sample patients (A1, A4, A5, A8, B1, B6, B7 and B8) were individualizedand related to identified patient problems and goals. Failure to document individualized social worker's ability to provide treatment and develop discharge plans to prepare the patient for successful re-entry into the community.

1. Patient A1's MTP, dated 4/06/10, listed the social work intervention for problem #1"Depressed Mood" as "Evaluate symptoms of depressed mood daily to assess pt's progress in order to plan treatment. Develop 1-3 community resources [sic]."

2. Patient A4's MTP, dated 4/09/10, listed the social intervention for problem #1"Depressed Mood" as "Evaluate symptoms of depressed mod daily in order to monitor [sic] current stressors. Develop 1-3 community resources with pt to assist his transition home."

3. Patient A5's MTP, dated 4/07/10, listed the social work intervention for problem #1 "Mood Lability" as "Patient to attend groups. Patient to learn coping skills in order to improve [sic] his feelings of depression, anxiety"

4. Patient A8's MTP, dated 4/09/10, listed the social work intervention for problem #1 "Depressed Mood" as "SW will discuss aftercare needs with pt and tx team in order to coordinate D/C planning."

5. Patient B1's MTP, dated 3/29/10, listed the social work intervention for problem #1 "Potential For self harm r/t mood instability" as "Pt will meet with staff to develop coping skills to better deal with mood & feelings to maintain and stabilize [sic]."

6. Patient B6's MTP, dated 4/09/10, listed the social work intervention for problem #1 "Potential for Self harm r/t depressed mood" as "Patient to attend groups. Patient to learn coping skills in order to alleviate his depression"

7. Patient B7's MTP, dated 4/09/10, listed the social work intervention for problem #1 "Potential For self harm r/t depressed mood" as "Patient to attend groups. Learn coping skills in order to alleviate [sic]"

8. Patient B8's MTP, dated 4/12/10, listed the social work intervention for problem #1 "Potential for self harm r/t mood instability" as "Evaluate symptoms of depressed mood daily in order to assess pt's current status [sic]. Develop 1-3 community supports with pt in order to assist pt's return to community"

Based on staff interview and record review, the facility failed to employ sufficient numbers of qualified Therapeutic Activities staff to complete assessments and ensure appropriate input into the formulation of the "Interdisciplinary Treatment Plan." Specifically, there were no Activities Therapists available to complete assessments as stipulated in the facility's "Plan of Professional Services." There was only the Director of Therapeutic Activities and two therapy aides available to conduct therapeutic activities for patients on the UNIT with 20 beds and the INN with 39 beds. In addition, the facility failed to ensure that therapeutic activities were available for patients after 3:00 p.m. during the week and on the weekends at the INN. This failed practice results in a limited number of planned therapeutic activities available to assist patients with skills necessary for relapse prevention and successful discharge.

Findings are:

A. Document Review

1. A review of the personnel file for the Director of Therapeutic Activities (TA) revealed the Director did not have appropriate training and education regarding leadership and clinical practice related to Therapeutic Activities. The Director had a bachelor's degree in Criminal Justice. A consultant was only available 4 hours per week to assist with running and coordinating this department, which was responsible for providing therapeutic activities to patients. The facilities document entitled "A Plan for Professional Services" noted, "Rehabilitation Activities are an integral part of treatment, which includes recreational, occupational and activities therapy. Soon after admission, patients are assessed for their cognitive, social, vocational and recreational skills, as well as their strengths and needs." Except for the Occupational Consultant, there were no recreational, occupational and activities therapists employed by the facility to complete TA assessments. There was no Therapeutic Activities assessment in the medical record that contained the content outlined in the "Plan for Professional Services."

2. A review of the "Group Schedule" for the INN revealed that therapeutic activities were scheduled for three days per week. The only planned activity on the schedule was the "Open Rec. Group." There were no therapeutic activities offered after 3:30 p.m. during the week and no therapeutic activities offered on Saturdays and Sundays.

3. A review of the "Group Evaluation Forms" revealed that staff were not documenting in the medical record or "Group Evaluation Forms" to show whether planned therapeutic activities were held or not held. There was no documentation for 4 for 4 active sample patients at the INN (A1, A4, A5, & A8). For Patient A4, who was admitted directly to the INN Building, there was no documentation of TA groups. For patients A1, A5, and A8, there was no documentation found in the medical record or on The "Group Evaluation Forms," once the patients were transferred to the INN Building. (Refer to B124)


B. Staff Interviews

1. In an interview on 4/13/10 at 11:30 a.m., the Director of Therapeutic Activities stated that he has been the Director for 2 years and has a Bachelor's Degree in Criminal Justice. He stated that he had received on-the-job training in Therapeutic Activities and started at the hospital as a MHA. He stated that he and two Therapy Aides conduct groups and attend treatment planning meetings and that "Therapy Aides" complete the treatment plans. He noted that he received consultation from an Occupational Therapist.

2. In an interview on 4/14/10 at 10:00 a.m., the Occupational Therapist Consultant stated that she provides 4 hours per week of consultation to the Director of Therapeutic Activities. She stated, "There is no formal Activities Assessment. Therapeutic Activity Staff go by the Nursing Assessment." She also stated that the hospital "could benefit from someone with clinical knowledge to ensure input into treatment and that things run effectively. They [Therapeutic Activity Staff] are doing the best they can with what they have."

3. In an interview on 4/14/10 at 11:35 a.m. with the Occupational Therapy Consultant and Director of Therapeutic Activities, documentation for groups and the availability of therapeutic activity groups was discussed. They confirmed that there were no Therapeutic Activities available after 3:30 p.m. and no Therapeutic Activities were scheduled on Saturday and Sundays for patients at the INN. The Director of Therapeutic Activities confirmed that there was no documentation of TA groups held for patients at the INN.